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JAMES 

A    Nan 

ica. 

Clinical ' 

Surgical 
orders. 

Surgical 

The  Prac 

BOOKS 

BY 

G.  MUMFORD, 

M.  D. 

Amer- 
1903 

1903 

e     Dis- 

id  1907 

Essays. 
J908 

I9t0 

ative    of     Medicine    in 

Talks  on  Minor  Surgery- 

Aspects     of     Digestiv 
1905  ai 

Memoirs    and    Other 
;tice  of  Surgery. 

Ik..  1.      An  ( )i.i>  time  Operating  Room. 
The  dome-amphitheater,  Massachusetts  General  Hospital.     The  first  public  demonstration  of 
ether   anesthesia,   October   16,    1846.       (After  the  well-known   painting,    m    the   Boston   Medical 
Library,  by  Hobert  Hinckley.; 


Fig.  2. — A   Modehn   Oper.\ting  Room. 
The  Bifielow  amphitheater,  Massachusetts  General  Hospital.     A  meetinK  of  the  Society  of  Clinical 

Surgery,  May  1,  1908. 


THE 


PRACTICE  OF  SURGERY 


BY 

JAMES  GREGORY  MUMFORD,  M.  D. 

VISITING    SURGEON'    TO    THE   MASSACHUSETTS   GENERAL    HOSPITAL;     INSTRUCTOR     IN    SURGERY 

IN    THE    HARVARD     MEDICAL    SCHOOL,"     FELLOW    OF    THE    AMERICAN 

SURGICAL    ASSOCIATION,    ETC. 


IVITH  682  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 

W.   B.   SAUNDERS  COMPANY 

1910 


/3-  ^K^b'/ 


Copyright,   1910,  by  W,  B.  Saunders  Company 


PRESS      OF 
AUNDERS       COM  PAN Y 
=  H  I  U  A  D  E  l_  P  H  I  A 


f) 


To  my  friends  and  associates 

in  the 

Society  of  Clinical  Surgery 


The  Wisdom  of  God  receives  small  honour  from 
those  vulgar  Heads  that  rudely  stare  about, 
and  with  a  gross  rusticity  admire  His  works: 
those  higlily  magnifie  Him,  whose  judicious 
inquiry-  into  His  Acts,  and  deliberate  research 
into  His  Creatures,   return  the  duty  of  a  devout 
and  learned  admiration. 

Religio  Medici. 


PREFACE 


In  this  writing  I  present  a  short  treatise  on  the  Practice  of  Sur- 
gery. Perhaps  the  title  ''  CHnical  Surgery"  would  equally  describe 
the  work.  I  omit  consideration  of  the  'princi'ples  of  surgery,  except 
incidentally  and  when  the  course  of  the  argument  seems  to  call  for 
such  consideration.  Within  youthful  memory  even  the  field  of  surgery 
has  broadened  so  enormously;  so  many  new  subjects  have  come  within 
its  embrace ;  knowledge  of  its  manifold  expression  has  become  so  exten- 
sive ;  its  study  is  now  found  to  expand  into  so  many  branches,  and  its 
roots  to  penetrate  so  deeply,  that  a  sound,  comprehensive  knowledge 
of  all  its  parts  is  no  longer  possible  to  a  single  individual,  or  to  be  con- 
densed as  I  wish  to  condense  this  work. 

When  men  of  my  generation  were  young  their  studies  in  surgery  were 
regarded  as  reasonably  complete  when  they  had  grounded  themselves  in 
gross  and  surgical  anatomy,  in  general  pathology,  in  such  simple  bac- 
teriology as  was  then  taught,  and  in  operative  technic.  To-day  studies 
in  surgery  embrace  an  immensely  wider  field.  Surgical  pathology  has 
grown  until  that  branch  alone  has  become  the  object  of  a  teacher's 
undivided  efforts.  Special  inquiry  into  particular  diseases,  processes, 
and  lesions  absorbs  individual  investigators.  Studies  in  bacteriology, 
in  questions  of  immunity,  in  serum  and  opsonic  therapy,  in  the  blood, 
in  tumors,  in  neurologic  surgery,  in  gastro-intestinal  surgery,  in  dis- 
eases of  the  eye,  the  ear,  the  throat ;  in  surgical  physiology  and  number- 
less kindred  topics,  have  become  so  far  reaching  and  diffuse  that  no  one 
mind  can  master  their  infinite  variety. 

The  situation  is  different  from  what  we  knew  when  a  single  teacher 
could  instruct  his  classes  in  all  there  was  to  know  of  surgery;  when  a 
general  surgeon  was  thought  competent  to  practice  in  every  field. 

To-clay  the  practitioner,  as  well  as  the  student,  must  acquire  knowl- 
edge in  special  laboratories,  under  special  teachers,  and  from  special 
books,  before  he  is  thought  competent  to  take  up  his  clinical  work ;  while 
clinical  work  and  teaching  alone,  with  such  a  background  of  study  as  I 
have  described,  must  be  the  task  of  specially  qualified  persons,  whose 
function  it  is  to  follow  the  'practice  of  surgery.  Every  surgical  clinician 
ma}^  have  his  particular  interest,  his  skill  in  some  branch  of  knowledge 
or  research,  but  he  cannot  be  a  sound  exponent  of  all  surgical  knowl- 
edge. 

And  so  it  must  be  with  a  treatise  on  the  Practice  of  Surgery.  As 
a  general  surgeon,  I  may  not  attempt  to  deal  comprehensively, 
accurately,    and   scholarly  with   all  branches  of  surgery.     Writers  of 


8  rilEFACE 

text-books  on  Medical  Practice  have  learned  something  of  this.  They 
no  longer  fill  their  pages  with  elaborate  essays  on  theory  as  well  as  on 
practice. 

In  this  book,  accordingly,  I  give  to  the  reader  an  account  of  the  prac- 
tice of  surgery — of  surgery  as  he  will  see  it  at  the  bedside,  in  the  accident 
ward,  and  in  the  operating-room.  The  writing  is  elaborated  from 
many  years  of  active  hospital  and  private  surgical  practice,  from 
clinical  teachings,  from  class-room  discussions,  and  lectures.  With 
proper  modesty  may  I  hope  that  the  student  will  find  here  a  com])rc- 
hensive  description  of  all  such  general  surgical  ailments  as  may  fall  to 
him  for  treatment  and  advice. 

Moreover,  the  reader  will  find  the  plan  of  this  book  somewhat  un- 
conventional in  other  respects.  I  puipose  taking  up  surgical  diseases 
in  their  order  of  interest,  importance,  and  frec|uency,  so  far  as  one  may 
with  due  regard  to  a  proper  sequence;  and  I  endeavor  also  to  lay  stress 
on  those  subjects  which  nature  herself  has  accentuated.  By  such  a 
plan  one  should  be  able  to  present  the  various  subjects  in  their  true 
perspective.  Appendicitis  concerns  us  far  more  than  does  inflammation 
of  Meckel's  diverticulum;  meningitis,  than  cirsoid  aneurysm;  and  felon, 
than  Dupuytren's  contraction.  The  student  should  leani  to  look  for, 
to  recognize,  and  to  treat  the  common  and  grave  ailments  which  practice 
furnishes.  Curiosities  of  surgery  should  be  known,  but  their  infrequency 
will  limit  their  familiar  study  by  the  average  practitioner.  For  this 
reason  their  exhaustive  exposition  must  be  left  to  writers  of  especial 
monographs.  Frequently  one  finds  essayists  complaining  that  their  own 
immediate  topics  are  slighted  by  the  writers  of  text-books.  In  the 
nature  of  text-book  composition  such  slighting  is  inevitable.  A  text- 
l)ook  of  surgery  cannot  be  an  encyclopedic  treatise  on  all  surgical 
knowledge. 

In  this  book,  therefore,  I  assume  the  reader's  preliminary  training, 
and  endeavor  to  present  to  him  the  Practice  of  Surgery  as  surgeons  see 
it — as  a  subject  of  unending  variety  and  importance,  as  a  pursuit  of 
the  deepest  human  interest. 

I  thank  cordially  my  friends  who  have  assisted  me  by  their  criticism 
in  the  final  revision  of  the  manuscript:  Dr.  Malcolm  Storer,  Dr.  Thomas 
F.  Harrington,  Dr.  E.  W.  Taylor,  Dr.  R.  B.  Greenough,  Dr.  Lincoln 
Davis,  Dr.  Samuel  Robinson,  and  Dr.  John  B.  Hartwell. 

The  original  illustrations  are  by  Miss  Ruth  O.  Huestis,  an  indefatig- 
able artist. 

J.  G.  M. 
29  Commonwealth  Ave., 

Boston,  Mass., 

September,  1910. 


CONTENTS 

PART   I— THE   ABDOMEN 

CHAPTER  I 

PAGE 

Appendicitis 17 

FoiTus  of  Appendicitis 23 

Symptoms  of  Appendicitis 26 

Diagnosis  of  Appendicitis 30 

Treatment  of  Appendicitis 31 

CHAPTER  II 

The    SiL\LL    IXTESTINE    AND    COLON 42 

Symptoms 46 

Intestinal  Obstruction 47 

Injuries 54 

Foreign  Bodies 56 

Meckel's  Diverticulum 57 

Enteroptosis 60 

Colitis 63 

Typhoid  Perforation ■ 64 

Tuberculosis  of  the  Intestines 67 

Actinomycosis  of  the  Intestines 69 

Embolism  and  Thrombosis  of  the  Mesenteric  Vessels 71 

Intussusception 73 

Volvulus 75 

Internal  Hernise 76 

Idiopathic  Dilatation  of  the  Colon 76 

Tumors  of  the  Intestine 76 

Fecal  Fistula  and  Artificial  Anus 82 

The  Mesentery  and  Omentum 87 

CHAPTER  III 

The  Rectum  and  Anus 89 

Hypertrophy  of  the  Rectal  Valves 90 

Imperforate  Anus 90 

Inflammations 92 

Fissure  of  the  Anus 94 

Ischiorectal  Abscess 95 

Fistula  in  Ano 97 

Hemorrhoids , 99 

Prolapse  of  the  Anus  and  Rectum 102 

Stricture  of  the  Rectum 104 

Tumors  of  the  Anus  and  Rectum 105 

CHAPTER  IV 

The  Esophagus,  Stomach,  and  Duodenum 113 

The  Esophagus 114 

Stricture  of  the  Esophagus 115 

Cardiospasm 120 

Diverticulum  of  the  Esophagus 122 

Foreign  Bodies  in  the  Esophagus 123 

Tumors  of  the  Esophagus 125 

Injuries  of  the  Esophagus 126 

Inflammations  of  the  Esophagus 127 

9 


10  CONTENTS 

Thk  Esophagus,  Stomach,  axd  Dtodp.nt.m   (Continued).  paoe 

The  Stomach 127 

Peptic  Ulcer 12'.i 

Pyloric  OVxstructiou 131) 

Ili'iuorrliii^c 141 

Perforation 142 

Distortion  of  the  Stomach 142 

Gastric  Adhesions 143 

Gastric  Tetany 144 

Gastric  Cirrhosis 144 

Spasm  of  the  Pylorus 144 

Gastroptosis 144 

Stenosis  of  the  Pylorus 1 45 

P'oreign  Bodies 145 

Cancer 145 

Sarcoma 153 

Wounds 154 

CHAPTER  V 

The  Liver  and  Bile-passages 155 

The  Liver 155 

Abscess  of  the  Liver 156 

Cysts  of  the  Liver 157 

Injuries  of  the  Liver 158 

Tumors  of  the  Liver 159 

Cirrhosis  of  the  Liver 163 

Hepatoptosis .^ 165 

The  Bile-passages 167 

CHAPTER  VI 

The  Pancreas  and  Spleen 181 

The  Pancreas 181 

Inflammations — Pancreatitis 181 

Tumors 184 

Traumatic  Injuries 186 

The  Spleen 187 

Injuries 187 

Abscess  and  Tuberculosis 188 

Cysts 188 

Neoplasms 189 

Splenic  Enlargement 1 89 

Ptosis 190 

CHAPTER  VH 

Abdominal  Hernia 192 

Inguinal  Hernia 199 

Femoral  Hernia 213 

Umbihcal  Hernia 215 

Ventral  Hernia 219 

Diaphragmatic  Hernia 220 

Obturator  Hemia 221 

Retroperitoneal  Hemia 221 

CHAPTER  YUI 

Peritoneum  and  Retroperitoneal  Space 223 

Acute  Peritonitis 223 

Diffuse  Peritonitis 225 

Chronic  Peritonitis 234 

The  Retroperitoneal  Space 238 

CHAPTER  IX 

Ptosis  of  the  Abdominal  Organs — The  Abdominal  Wali 243 

Abdominal  Ptosis 243 

The  Abdominal  Wall 251 


CONTENTS  11 

PART  II— FEMALE  ORGANS  OF  GENERATION 

CHAPTIOR  X 

PACE 

The  Uterus 255 

Aiuitoinj' 255 

Inttaiuiuatiou 261 

Lacerations 272 

Wounds 274 

Displacements 275 

Tumors 292 

Myoma 292 

Cancer 305 

Endothelioma 317 

Sarcoma 317 

Deciduoma  Malignum 318 

CHAPTER  XI 

Fallopian  Tubes  and  Ovaries 319 

The  Fallopian  Tubes 319 

Salpingitis 319 

Tumors 329 

The  Broad  Ligaments 330 

The  Ovaries : 331 

Ovaritis 331 

Tumors 333 

Tubal  Pregnancy 340 

Pelvic  Hematocele 344 

CHAPTER  XII 

Perineum  and  Vagina 345 

Perineal  Lacerations 345 

Urethral  Caruncle 352 

The  Vulva 352 

The  Vagina 353 

Vaginal  Fistulse 353 

Inflammation 357 

Vaginal  Cysts 357 

Atresia  of  the  Vagina 357 


PART   III-GENITO-URINARY   ORGANS 

CHAPTER  XIII 

Kidneys  and  Ureters 358 

Anatomic  Relations 358 

Diagnosis  in  Renal  Disease 360 

Injuries  of  the  Ividney , 366 

■Stone  in  the  Ividney 369 

Hydronephrosis 374 

Pyelitis 375 

Tuberculosis  of  the  Kidney 380 

Tumors  of  the  Ividney  and  Suprarenal  Gland 382 

Lumbar  Fistula " 386 

Chronic  Nephritis 386 

CHAPTER  XIV 

Bladder  and  Prostate 388 

The  Bladder 388 

Exstrophy  of  the  Bladder 388 


12  CONTENTS 

Bladdkh  and  Prostate  (Continued).  page 

Absence  of  the  Bladder,  Double  Bladder :i8*J 

Reteiit ion  of  Urine 390 

Cystitis 394 

Stone  in  the  Bladder 398 

Uleer  of  the  Bladder 404 

Tumors  of  the  Bladder 40."> 

Sacculation  of  the  Bladder 408 

Bladder  Injuries 409 

The  Prostate 411 

Anatomy  of  the  Prostate 411 

Inflammation  of  the  Prostate 412 

Prostatic  Calculi 414 

Hypertrophy  of  the   Prostate 415 

Cancer  of  the  Prostate 428 

CHAPTER  XV 

Penis,  Urethra,  and  Testes 433 

The  Penis  and  Urethra 433 

Gonorrhea 434 

The  Genital  Lesions  of  Syphihs 444 

Injuries  of  the  Penis 447 

Genital  Herpes 448 

Venereal  Warts 448 

Circvmacidon 448 

Cancer  of  the  Penis 450 

Foreign  Bodies  in  the  Urethra 451 

Para-urethral  Abscess 452 

Stricture  of  the   Urethra 452 

Urethral  Fistula 458 

ITrethroscopy 458 

Hypospadias  and  Epispadias 459 

The  Testicles 464 

Undescended  Testicle 464 

Wounds  and  Contusions 468 

Inflammation ' 468 

Hydrocele 470 

Varicocele 474 

Tumors 475 

Twisted  Cord 477 

Castration 477 


PART   IV— THE   CHEST 

CHAPTER  XVI 

The  Bronchi  and  Lungs 478 

Foreign  Bodies  in  the  Bronchi 479 

Bronchiectasis 480 

General  Teclmic  of  Operating  upon  the  Lungs 481 

CHAPTER  XVII 

The  Pleura 488 

Inflammatory  Disease 488 

Pyothorax 490 

CHAPTER  XVIII 

The  Heart  and  Pericardium 496 

Pericardial  Effusions 497 

Operations  upon  the  Pericardium 497 

Wounds  of  the  Heart 499 


CONTENTS  13 
CHAPTER  XIX 

PAGE 

The  Chest- wall — The  Breast 502 

The  Chest-wall 502 

Contusions  of  the  Chest 502 

Inflammations 503 

Neuritis  of  the  Intercostal  Nerves 504 

Tumors  of  the  Chest-wall 504 

The  Breast 505 

Anatomy 505 

Cancer 507 

Other  Breast  Tumors 524 

Mastitis 529 

Retention  Cysts 532 

Supernumerary  Breasts  and  Nipples 532 


PART  V— THE  FACE  AND  NECK 

CHAPTER  XX 

Harelip  and  Cleft-palate 533 

Harelip 534 

Cleft-palate 540 

Plastic  Operations  on  the  Face 544 

Salivary  Fistula 547 

Salivary  Stones 547 

Ranula 547 

Thyrolingual  or  Thyroglossal  Cysts  and  Sinuses 548 

Cancer  of  the  Lip 548 

Rodent  Ulcer 554 

Injuries  of  the  Face 555 

Tumors  of  the  Face 556 

CHAPTER  XXI 

Jaws,  Tongue,  Larynx,  and  Pharynx 558 

The  Jaws 558 

Infections 559 

Tumors 561 

The  Tongue 569 

Inflammation 570 

Cancer 571 

Sarcoma 574 

The  Salivary  Glands 574 

The  Pharynx  and  Nasopharynx 576 

Diseases  of  the  Larynx ■ 578 

CHAPTER  XXII 

The  Neck 586 

Cicatricial  Contractions .  .  .  : 586 

Torticollis 586 

Cervical  Adenitis 589 

Wounds  of  the  Thoracic  Duct 593 

Deep  Cervical  Abscess 594 

Pediculi  Capitis 594 

Lymphatic  Cysts 594 

The  Carotid  Gland 595 

Cervical  Rib 597 

Disease  of  the  Thyroid  Gland 597 

Goiter 602 

Epithelial  Diseases  of  the  Thyroid 610 


14  CONTEXTS 

PART  VI— THE  HEAD  AND  SPINE 

CHAPTER  XXIII 

PAGE 

The  Scalp 613 

Contusions  of  the  Scalp 614 

Tumors  of  the  Scalp 616 

CHAPTER  XXIV 

The  Skull,  Brain,  and  Meninges 619 

Fractures  of  the  Skull 620 

The  Meninges 642 

Developmental  Anomalies 643 

Hj'drocephalus 644 

Cerebrospinal  Rhinorrhea 645 

Sinus  Thrombosis 646 

Meningitis 647 

Meningeal  Tumors 650 

The  Cranium 650 

Tumors  of  the  Cranial  Bones 650 

The  Brain 652 

Encephalitis 652 

Cerebral  Abscess 652 

Tumors  of  the  Brain 653 

Results  of  Injuries  and  Diseases  of  the  Brain 658 

Intracranial  Operations 663 

CHAPTER  XXV 

The  Spixe  and  the  Peripheral  Xerves 669 

The  Spine .  669 

Anatomy  and  Physiologj-  of  the  Cortl 670 

Concussion  and  Contusion <)74 

Wounds  of  the  Cord .' 675 

Dislocations  and  Fractures  of  the  \'ertel3rse 676 

Spinal  Meningitis ■ 680 

Spina  Bifida 681 

Tumors  of  the  Spine 685 

The  Peripheral  Xer\'es 694 

X'euritis 695 

Xeuralgia 697 

Operations  upon  the  Xer\es 707 


PART  VII-MINOR    SURGERY.    DISEASES  OF  STRUCTURE 

CHAPTER  XXVI 

Minor  Surgery 719 

The  Examination  and  Study  of  Cases;   Wounds:   Fractures;    Local  Infec- 
tions:  Massage 719 

Incised  Wounds ■ 724 

Simple  (Closed )  Fractures 729 

Lacerated  Wounds 732 

Compound  ( Open)  Fractures 736 

Granulating  Wounds  and  Varicose  Ulcers ^40 

Felon:  Whitlow;  Paronychia:  Palmar  Abscess 745 

Boils:   Carbuncles 'j2^ 

Bunions;   Ingrowing  Nails;  'Corns;  Warts i_'>( 

Massage '^^ 


CONTENTS  15 

CHAPTER  XXVII 

PAGE 

Shock;  Blood-vessels;  Lymphatics;  Muscles;  Tendons;  Burs.e;  Skin...  767 

Shock  and  Collapse "67 

Suro;eiy  of  the  Blood-vessels 772 

"  Pfdebitis "73 

Angioma 776 

The  Arteries 776 

Ligation  of  the  Arteries 776 

Aneurysm 783 

Suture  of  the  Blood-vessels 792 

Surgeiy  of  the  Lymphatic  System 792 

Lymphangitis 794 

Lymphangioma,  Lymph  Varices,  Lymphangiectasis,  and  Lymphaden- 

ocele 796 

Lymphadenitis 798 

Hodgkin's  Disease 799 

Surgery  of  the  Muscles,  Tendons,  and  Bursse 801 

Muscles 801 

Tendons 803 

Bursa? 808 

Surgery  of  the  Skin 812 


CHAPTER  XXVIII 

Tumors 818 

Classification :  .  .  .  .  819 

Causation 819 

Cysts 820 

Dermoids  and  Teratomata , 824 

Tumors  of  the  Connective-tissue  Type 826 

Epithelial  Tumors 838 

Cancer 842 


CHAPTER  XXIX 

Fractures  and  Dislocations 849 

Fractures 849 

General  Considerations 850 

Simple  Fractures 854 

Compound  Fractures • 858 

Special  Fractures  and  their  Treatment 859 

Ribs 859 

Sternum 861 

Pelvis 862 

Clavicle 863 

Scapula 867 

Humerus °"° 

Elbow , 877 

Forearm 884 

Colles'  Fracture 886 

Carpus 891 

Metacarpal  Bones 892 

Phalanges 895 

Femur 895 

Patella 904 

Leg 907 

FoSt 916 

Face 917 

Pathologic  Fractures 9^4 

Dislocations 9-4 

Special  Dislocations 926 


16  CONTEXTS 

CHAPTER   XXX 

PAGE 

Bones  and  Joints  (Okthoi'edic  Surgery) 943 

The  Hones 943 

Tlie  Joints 955 

CHAPTER  XXXI 

Amputations 974 

Special  Amputations 981 


Index 993 


THE  PRACTICE  OF  SURGERY 


PART  I 

THE  ABDOMEN 


CHAPTER  I 
APPENDICITIS 


Appendicitis,  more  than  any  other  acute  disease,  interests  all 
classes  of  the  community.  It  is  everywhere  present;  it  is  serious  and 
alarming;  it  appears  under  many  guises  and  passes  through  many 
phases;  it  calls  for  heroic  treatment;  its  study  has  been  developed  and 
formulated  in  our  own  generation,  and  so  has  become  a  favorite  theme 
of  modern  surgeons ;  about  it  have  centered  some  of  the  most  stimulating 
and  vital  medical  discussions  of  our  time,  and  in  the  great  majority  of 
cases  it  can  be  cured. 

The  history  of  appendicitis  is  recent,  because  so  lately  as  1886  only 
was  its  nature  properly  demonstrated, "^  but  for  generations  there  were 
knowledge  and  fear  of  attacks  of  pain  and  inflammation,  often  fatal,  in 
the  right  lower  portion  of  the  abdomen.  Sporadic  accounts  of  cases 
appear  far  back  in  medical  literature,  and  are  recorded  by  French, 
Italian,  and  English  reporters  of  the  last  three  centuries.  In  the 
nineteenth  century,  and  with  the  development  of  abdominal  surgery, 
following  Lister's  teaching,  our  attack  upon  this  disease  became  more 
concentrated  and  effective.  The  Englishman  Hancock,  and  the  New 
York  surgeons  Willard  Parker  and  Gurdon  Buck,  opened  abscesses  in 
the  right  iliac  fossa  fifty  years  ago.  In  1886  R.  H.  Fitz,  of  Boston,  ex- 
plained the  nature  of  the  process,  while  J.  Homans,  C.  McBurney, 
C.  B.  Porter,  M.  H.  Richardson,  J.  B.  Deaver,  and  many  recent  operators 
have  developed  and  perfected  a  technic  for  dealing  with  the  disease  in 
both  its  acute  and  quiescent  stages. 

The  anatomy  of  the  vermiform  appendix  is  important.  The  little 
organ  lies  in  the  right  iliac  and  hypogastric  regions,  in  its  typical  posi- 
tion hanging  down  over  the  brim  of  the  pelvis ;  but  it  may  swing  in  any 
direction,  from  its  base  as  an  axis.     Occasionally  it  lies  entirely  behind 

^  R.  H.  Fitz,  Perforating  Inflammation  of  the  Vermiform  Appendix,  Trans. 
Assoc.  Amer.  Physicians,  June,  1886. 

2  17 


18 


THE   ABDOMEN 


the  cecum.  Its  most  common  length  is  between  2  and  3.2  inches; 
rarely,  one  sees  removed  a  great  appendix,  5,  9,  and  even  10  inches  long. 
The  lumen  is  from  0.1  to  0.2  inch  in  diameter.  At  its  entrance  into 
the  cecum  is  a  fold  of  mucous  membrane  known  as  the  valve  of  Gerlach. 


Fig.  3. — Normal  vermiform  appendix. 

In  a  few  reported  cases  no  appendix  has  been  found.     Let  me  remind  the . 
student  that  in  the  development  of  the  fetus  the  cecum  and  appendix 
descend  from  high  up  under  the  liver,  in  which  position  the  appendix  is 


Fig.  4. — Diagram  showing  unusually  long  appendix. 

an  organ  of  considerable  size.*  At  the  fourth  month  of  intra-uterine 
life  the  size  of  the  appendix  is  to  the  cecum  as  about  1  is  to  5.  At  birth 
it  approximates  to  the  adult  size  and  foi-m,  its  proportion  to  the  cecum 

1  In  herbivora  no  true  appendix  is  found,  but  a  large,  useful,  and  dilatable 
second  cecal  pouch.  In  carnivora  this  pouch  has  shrunk  to  the  apparently  useless 
appendix  or  has  disappeared. 


APPENDICITIS 


19 


bein"-  about  1  to  15.  As  infancy  and  youth  advance,  this  disproportion 
becomes  more  and  more  marked,  until  the  cecum  has  overgrown  and 
crowded  the  appendix  to  such  an  extent  that  the  latter  has  been  pushed 
upward,  backward,  and  usually  inward,  so  as  to  appear  as  a  mere  spiral 


Ficr    5  —Normal  position  of  appendix  and  cecum    with  transverse  colon  raised; 
^'     '  dotted  line  showing  natural  position  of  transverse  colon. 

projection  from  the  posterior  aspect  of  the  cecum.  This  position  it 
reaches  about  the  fifth  year.  Commonly,  one  finds  the  appendix 
swinging  loosely  in  a  fold  of  peritoneum,  which  forms  its  mesentery,— 
the  meso-appendix,— and  carries  its  blood-supply,  nerves,  and  lymph- 
vessels. 


20  THE    ABDOMEN 

The  artery  of  the  appendix'  springs  from  the  superior  mesenteric, 
and  feeds  the  organ  through  a  number  of  branches.  The  nerve  distribu- 
tion is  shared  with  the  small  intestine  and  the  stomach;  the  muacular 
mechanism  runs  to  the  cecum.-  The  significance  of  this  divergent 
arrangement  will  be  seen  when  we  consider  the  etiology  of  appendicitis. 
"While  the  wall  of  the  appendix  resembles  that  of  the  cecum,  its  mucous 
membrane  is  far  richer  in  lymph-glands,  which  are  intimately  concerned 
wath  its  inflammatory  processes.  The  organ  practically  is  always 
CO  vexed  with  peritoneum,  but  its  freedom  of  movement  and  its  variable 
position  have  an  im})ortant  bearing  on  the  extent  and  severity  of 
inflammation  originating  in  it.  When  free  in  the  general  peritoneal 
cavity,  it  is  obviously  a  source  of  more  serious  danger  than  when  tucked 
away  behind  the  cecum .^ 

The  function,  or  lack  of  function,  of  the  vermiform  appendix  is 
the  subject  of  an  interesting  chapter,  and  the  question  is  closely  allied 
to  the  rather  intricate  anatomy  at  which  we  have  glanced.  The  process 
of  shrinking  of  the  appendix  by  no  means  stops  with  the  fifth  year.* 
Obliteration  continues.  From  the  fifteenth  year  on  a  small  but  increas- 
ing proportion  of  appendices  are  found  to  be  cut  off  from  the  gut, 
through  changes  in  their  mucous  lining.  By  the  thirty-fifth  ^-ear  this 
proportion  is  said  to  have  reached  25  per  cent.,  and  so  on  until,  by  the 
sixty-fifth  year,  it  has  reached  nearly  70  per  cent.  This  corresponds 
to  the  lessened  liability  to  appendicitis  with  advancing  years.  On  the 
other  hand,  the  appendix,  or  cecoappendix,  as  the  complete  cecum- 
plus-appendix  has  been  called,  appears  to  have  a  distinct  function  in 
secreting  a  fluid  which  aids  in  digestion  and  absorption  and  in  controlling 
materially  the  action  of  the  bacteria  always  present  there  in  great 
numbers." 

In  the  etiology  of  appendicitis  we  find  that  the  various  factors 
already  mentioned  have  an  immediate  bearing  upon  the  process.  It 
is  obvious  that  appendicitis  is  of  bacterial  origin,  and  the  question  is, 
How  do  the  bacteria  gain  a  lodgment  in  the  tissues  and  produce  dis- 
turbance? Pus-cocci  and  the  Bacterium  coli  commune  are  the  most 
common  offenders.  We  know  that  bacteria,  when  they  are  retained 
under  pressure,  may  enter  into  the  tissues.  A  congestion  of  the  cecal 
mucous  membrane  ma}'  obstruct  the  valve  of  Gerlach;  the  appendix 
then  becomes  distended  with  mucus  loaded  with  bacteria;  localized 

1  A  secondary  blood-supply  in  women  is  sometimes  described  as  reaching  the 
appendix  tlirough  tlie  appendiculo-o\-arian  or,  more  properly,  the  suspensory 
ligament.  Such  a  blood-supply,  as  well  as  a  lymphatic  supply  by  the  same  route, 
is  problematic,  though  it  has  occasionally  been  descrilied.  Embrj'ologicany,  it  is  a 
paradox  {vide.  D.  H.  Craig,  Clinical  Experiences  with  the  Appendiculo-ovarian 
Ligament,  Amer.  .Jour.  Obstet.  and  Dis.  of  ^A■omen,  1904,  vol.  1,  No.  3. 

2  McEwen,  Function  of  Cecum  and  Appendix,  Lancet,  October  8.  1904. 

3  W.  A.  Brooks,  .Jr.,  Boston  Med.  and  Surg.  Jour.,  190.S,  vol.  cliii.  p.  358,  refers  to 
a  "subject  of  a  sixteen-year-old  girl  at  tlie  Harvard  Medical  Sciiool.  .  .  The 
ascending  colon  is  completely  unattached  to  the  posterior  abdominal  wall,  except 
by  the  root  of  its  me.senterj'.  The  appendi.x  may  be  placed  at  almost  any  point  in 
the  abdominal  cavity." 

*  Woods  Hutchinson,  Appendicitis  as  an  Incident  in  Development,  Amer.  Med., 
August  1,  1903.  5  McEwen,  ibirf. 


APPENDICITIS 


21 


necrosis  follows;   the   bacteria   enter  the   tissues,  and  the   mischief   is 
done.^ 

McEwen-  makes  the  observation  that  since  the  appendix  shares 
in  the  nerve  distribution  of  the  small  intestine  and  stomach,  therefore, 
under  normal  conditions  of  health,  food  high  up  in  the  gut  stimulates 
the  appendix,  which  proceeds  to  pour  out  its  secretion  long  before  the 
chyle  reaches  it.  Conversely,  irritating  substances  in  the  stomach 
or  small  intestine  will  disturb  the  nerve  mechanism  of  the  appendix,  so 
that  its  secretion  is  checked,  and  the  cecum  remains  dry;  consequently 
bacteria  multipl}^  and  act  viciously,  especiall}'  if  there  be  temporary 
obstruction  to  the  outlet  of  the  appendix.  Such  irritation  and  obstruc- 
tion will  prove  a  still  more  serious  matter  if  the  appendix  be  adherent 
or  kinked  from  a  previous  inflammation,  or  if  the  normal  process  of 


•Fig.  6. — Valves  of  the  ileum  and  appendix  (open  and  closed). 

obliteration  has  caused  stenosis  of  the  appendix  outlet.^  The  ancient 
impression  that  these  appendix  inflammations  are  due  to  foreign  bodies 
or  even  to  fecal  concretions  lodged  in  the  appendix  is  seldom  true, 
though  it  is  conceivable  that  such  a  body  might  close  the  valve  of  Ger- 
lach*  or  even  cause  mechanical  erosions,  with  a  consequent  train  of 
destructive  changes. 

Alterations  in  the  blood-supply  of  the  appendix  were  at  one  time 
regarded  as  the  cause  of  appendicitis,  but  although  such  arterial  changes 

^  C.  Van  Zwalenburg,  Jour.  Amer.  Med.  Assoc,  March  26,  1904,  under  the  cap- 
tion, Obstruction  and  Consequent  Distention  the  Cause  of  Appendicitis,  records  some 
interesting  observations  bearing  on  this  point.  -  Ibid. 

3  Ribbert  and  Zuckerkandl  found  a  partial  or  complete  closure  of  the  appendix 
in  about  25  per  cent,  of  the  cases  examined. 

•*The  existence  of  which  is  questioned  by  George  Woolsey  and  other  sotmd 
writers. 


22  THE    ABDOMExX 

are  found,  it  is  likely  that  they  are  usually  secondary  and  not  primary. 
Exposure  to  cold,  influenza,  and  rheumatism  have  been  mentioned  as 
causes  of  appendicitis,  through  their  producing  swelling  of  the  mucosa 
and  obstruction  of  the  lumen.  There  is  little  evidence  that  such  causes 
are  frecjuent. 

Pathologic  Anatomy. — Any  surgeon  of  experience  will  tell  you  that 
he  learns  something  new  from  every  case  of  appendicitis,  because  cases 
differ  so  constantly  in  detail,  and  because,  frequently,  the  symptoms 
and  signs  fail  as  guides  to  the  conditions  actually  present.  The  terms 
appendiceal  colic,  catarrh  of  the  appendix,  hydrops  of  the  appendix,  acute 
appendicitis,  gangrenous  appendicitis,  relapsing  appendicitis,  chronic 
appendicitis,  etc.,  are  common.  Let  us  study  the  conditions  which 
may  justify  these  terms.  Bearing  in  mind  the  normal  obliterative 
process  which  is  seen  in  great  numbers  of  appendices,  we  must  conclude 
that  this  process  of  obliteration  may  enter  at  times  into  the  problem 
of  abnormal  pathologic  conditions.  It  does  not  seem  pro))able  that 
''appendiceal  colic"  is  a  term  which  should  be  apphed  to  any  clearly 
recognized  process.  At  any  rate,  if  there  be  such  a  condition,  it  is  not 
demonstrable.  But  there  may  be,  and  unquestionably  are,  colicky 
pains  due  to  temporary  obstruction  of  the  appendix  lumen,  with  conse- 
quent distention,  which  subsides,  leaving  no  trace  behind.  As  a  general 
thing,  however,  some  form  of  inflammation  is  associated  with  pain  in 
this  region,  and  such  inflammations  may  vary  in  degree  within  the 
widest  bounds.  We  may  have  a  simple  catarrh  of  the  mucous  mem- 
brane, with  a  reddened  and  swollen  mucosa  and  an  abundant  secretion. 
With  this  there  will  be  found  an  infiltration  of  small  round-cells  into 
both  the  mucosa  and  the  submucosa,  with  swelling  of  the  follicles.  An 
appendix  so  affected  appears  thicker  and  stiffcr  than  normal.  There  is 
probably  almost  always  some  obstruction  to  the  outlet  from  this  cause, 
so  that  the  appendix  becomes  distended  with  mucus  and  fecal  matter. 
These  are  the  cases  w^hich  subside  and  recur  without  marked  and  per- 
manent damage  to  structure,  though  there  maj'  be  erosions  and  conse- 
quent cicatrices  if  the  process  is  frequently  repeated.  Obviously, 
such  cicatrices  encourage  subsequent  attacks,  while  one  occasional 
result  of  such  attacks  is  a  cicatrix,  which,  by  its  contraction,  produces 
a  complete  stenosis.  In  such  cases  the  appendix  is  transformed  into 
a  retention  cyst.  The  contained  fluid  may  be  sterile  apparentlj^,  and 
the  C3'st  may  remain  for  a  long  period,  without  other  result  than  pain 
and  occasional  functional  disturbance.  On  the  other  hand,  the  retained 
fluid  may  become  septic — a  more  usual  result,  so  that  you  wdll  find  a 
purulent  fluid  within  the  appendix  associated  with  thinning  and  destruc- 
tive changes  in  the  walls.  Such  a  condition  may  be  likened  to  empyema 
of  the  gall-bladder.  Rarely,  the  cystic  tumor  may  grow  to  a  consider- 
able size,  even  as  large  as  the  closed  fist.  Such  are  the  conditions  known 
as  "  catarrhal  appendicitis"  and  "  suppurative  appendicitis  " ;  but  we  are 
coming  to  believe  that  they  are  less  common  than  was  supposed  at  one 
time,  or  more  properly  that  they  do  not  often  remain  innocent,  buf 
develop  into  more  alarming  forms  of  the  disease. 


FORMS   OF   APPEXDICITIS  23 

FORMS  OF  APPENDICITIS 

Acute  appendicitis,  often  perforative,  is  the  grave  and  urgent  con- 
dition which  is  commonly  meant  when  we  speak  of  appendicitis.  It 
ma}'  come  on  suddenly,  without  previous  warning,  or  it  may  develop 
out  of  a  previous  and  more  chronic  condition.  There  are  the  swelling 
and  obstruction  precedent;  the  mucosa  and  the  deeper  tissues  become 
infiltrated;  slight  hemorrhages  and  erosions  occur;  bacteria  find  their 
way  into  the  tissues;  the  appendix  becomes  enlarged  and  stiffened; 
active  ulceration  of  the  mucosa  may  supervene,  and  perforation  may 
quickly  follow  at  any  point  from  the  tip  to  the  base.  If  this  were  all, 
the  condition  would  be  found  uniform,  and  the  S3'mptoms  in  various 
cases  not  dissimilar,  but  the  student  must  remember  that  the  appendix 
is  a  movable  organ,  covered  with  peritoneum,  and  placed  variously  in 
its  relations  to  the  cecum  and  other  abdominal  viscera.  The  rate  of 
progress  of  the  infection  is  also  a  variable  quantitj-.  If  the  process  be 
delaj'ed  and  the  organisms  few  and  not  markedly  virulent,  the  case  may 
run  a  subacute  and  prolonged  course.  As  the  inflammation  extends 
through  the  coats  of  the  organ  an  injection  of  the  serosa  takes  place; 
mdeed,  that  is  a  frequent  and  earty  event,  and  fibrous  adhesions  quickly 
are  set  up.  In  the  great  majority  of  cases  such  adhesions  are  formed — 
this  is  nature's  protective  process.  The  appendix  becomes  glued  to  the 
surrounding  tissues  and  organs.  Frequently  one  finds  it  wrapped  up  in 
the  omentum,  which  presents  a  strong  barrier  to  the  progress  of  a 
dangerous  infection.  Along  with  the  inflammation  of  the  wall  of  the 
appendix  there  is  a  progressive  suppurative  thrombosis  of  the  appendix 
vessels,  with  destruction  of  tissue,  thus  establishing  a  vicious  circle, 
the  progress  of  the  primary  inflammation  affecting  the  vessels,  the 
affected  vessels  in  their  turn  failing  to  nourish  the  tissues,  and  conse- 
quently a  rapidly  spreading  necrosis  or  gangrene.  It  is  not  necessary 
that  the  perforation  be  macroscopic  or  even  microscopic  in  order  to  act 
upon  the  serosa,  for  infecting  material  may  reach  the  surface  without 
actually  breaking  down  in  necrosis  the  intervening  tissues.  However 
that  may  be,  with  involvement  of  serosa  and  neighboring  structures 
the  progress  of  the  disease  may  go  on  in  a  variety  of  ways.  The  infec- 
tion of  the  adhesions  about  the  appendix  may  spread,  involving  organs 
more  and  more  remote,  until  a  great  "  cake  "  or  matted  mass  of  viscera 
results.  In  such  cases  suppuration  usually  supervenes,  and  pus  collects 
in  pockets  about  the  appendix,  the  omentum,  and  among  the  coils  of 
intestines.  The  destructive  process  in  the  appendix  may  not  cease  with 
the  escape  of  infecting  contents  into  the  surrounding  tissues,  but  the 
necrosis  may  continue  until  the  organ  is  destroyed  or  sloughed  off, 
leavmg  a  mere  hole  or  stump  in  the  cecum  to  mark  its  site.  Sometimes 
several  sections  of  the  appendix  are  found  scattered  about  and  adherent 
through  the  mesentery  and  omentum. 

If  unchecked,  the  extension  of  suppuration  may  be  remarkable. 
Great  lakes  and  wells  of  pus  interspersed  among  matted  intestines  may 
fill  the  lower  part  of  the  abdomen  and  pelvis ;  sometimes  the  intestines 


24 


THE    ABDOMEN 


themselves  are  involved  in  necrotic  changes.  In  a  recent  case  of  two 
weeks'  standing  I  found  4  feet  of  ileum  detached  from  its  necrotic 
mesentery  and  floating  loosely  in  a  lake  of  pus.  In  this  case  the  appen- 
dix had  disappeared  and  was  represented  only  by  a  great  hole  in  the 
cecum,  from  which  poured  a  stream  of  feces. 

In  the  case  of  infections  of  the  appendix,  whether  or  not  there  be  pus 
present, — and  there  is  always  a  purulent-looking  fluid, — one  hopes  that 
the  process  will  remain  limited  and  will  not  invade  the  general  peritoneal 
cavity.  That  chance  of  such  an  invasion  and  the  consequent  great 
danger  to  life  are  possible ;  but  so  long  as  diffuse  peritonitis  has  not  oc- 
curred, the  chance  of  cure  is  considerable.  Let  us  consider  for  a  moment 
what  may  be  the  outcome  of  a  perforating  api^endicitis  if  left  to  nature. 
There  can  be  no  doubt  that  in  a  considerable  proportion  of  cases 
the  acute  process  begins  to  subside  after  the  fourth  or  fifth  day.  The 
abundant  lymphatic  connections  of  the  peritoneum  take  up  and  cany 
off  the  infecting  agents.     For  a  while  adhesions  become  more  dense  and 


Fig.  7. — Diagram  showing  segmented  appendix. 

incarcerate  the  disease.  Resolution  takes  place,  reparative  processes 
follow,  and  in  the  course  of  a  few  weeks  nothing  is  left  to  mark  the  seat  of 
trouble  save  a  few  adhesions  and  a  crippled,  distorted  appendix.  Even 
when  pus  is  present,  it  may  be  strongly  confined;  small  amounts  may  be 
absorbed,  and  large  amounts  may  find  exit  either  by  rupture  into  the 
intestines,  bladder,  or  vagina,  or  may  work  their  way  through  to  the 
skin  and  ''point"  externally.  This  tendency  of  pus  from  appendicitis 
to  burrow  in  sundry  directions  following  the  line  of  least  resistance  has 
given  rise  to  diverse  and  pvizzling  symptoms  and  signs.  We  see  ab- 
scesses pointing  in  either  inguinal  region,  burrowing  under  the  cecum, 
liver,  and  diaphragm,  and  breaking  into  the  lungs  and  bronchi,  followed 
by  the  expectoration  of  pus.  Pus  from  the  appendix  has  been  vomited 
and  has  been  passed  by  urethra  and  rectum.  I  have  seen  an  appendix 
abscess  pointing  in  the  prevesical  space,  and  it  is  not  uncommon  to 
have  the  abscess  open  in  the  lumbar  region. 

Such  abscesses  and  burrowings  of  pus  as  I  have  described  are  due  to 


FORMS   OF   APPENDICITIS  2'5 

the  course  of  the  disease  being  limited  and  directed  by  fibrinous  adhe- 
sions, or  to  the  appendix  itself  being  jDlaccd  in  unusual  positions — behind 
the  cecum,  under  the  liver,  adherent  to  the  bladder,  etc. 

The  conditions  which  we  have  been  considering  are  the  more  common 
and  are  those  least  likely  to  become  lethal,  but  there  is  a  development 
of  acute  appendicitis  which  is  far  more  grave — that  form  which  involves 
the  free  peritoneal  cavity,  which  spreads  rapidly,  and  usually  ends  in 
death  from  peritonitis.  Such  a  peritonitis  may  be  due  directly  to  a 
rapidly  perforating  appendicitis,  which  progresses  without  the  formation 
of  adhesions,  or  it  may  be  due  to  the  breaking-down  of  adhesions  and  to 
the  invasion  of  the  general  peritoneal  cavity  by  infective  material  from 
an  abscess.     We  shall  study  general  peritonitis  in  a  subsequent  chapter, 

There  are  other  forms  of  appendicitis  and  other  causes  than  those 
which  I  have  mentioned.  Appendicitis  may  be  due  to  tuberculosis  of 
the  appendix,  in  which  case  it  is  usually  associated  with  a  general  intesti- 
nal tuberculosis.  Writers  have  reported  appendicitis  due  to  irritation 
by  intestinal  parasites.  Moreover,  one  sees  occasionally  diseases 
simulating  appendicitis,  and  the  conditions  may  be  confused  with  fecal 
impactions,  gall-stone  colics,  renal  colics,  actinomycosis,  and  symptoms 
dependent  upon  visceral  ptosis.  Some  years  ago  I  reported  a  curious 
case  in  which  all  the  symptoms  of  appendicitis  appeared  to  be  present; 
but  upon  opening  the  abdomen,  I  found  the  appendix  normal,  while  a 
mass  of  dry  and  dense  orange-pulp  was  discovered  packing  the  caput 
cceci. 

Age  has  a  decided  bearing  upon  the  liability  to  appendicitis,  as  one 
would  expect  from  what  we  have  heard  of  the  developmental  and  obliter- 
ative  changes  in  the  appendix.  The  disease  is  most  common  between 
the  ages  of  fifteen  and  thirty,  and  decreases  in  frequency  after  that  time. 
Nevertheless,  we  are  finding  that  appendicitis  in  children  is  frequent, 
and  numerous  writers  have  reported  cases  from  the  age  of  one  year  and 
upward;^ 

Sex,  too,  has  been  regarded  as  having  a  bearing  upon  liability  to 
these  inflammations,  and  probably  men  are  affected  more  frequently 
than  women;  but  the  great  series  of  statistics  now  at  our  disposal  show 
that  women  are  not  infrequently  affected,  and  some  reporters  have 
recorded  more  women  than  men  in  their  lists.  Sometimes  it  appears  that 
there  is  a  family  predilection  for  appendicitis. 

We  use  the  terms  relapsing  appendicitis  and  chronic  appendi- 
citis— terms  indicating  conditions  which  merit  serious  study.  From 
our  discussion  of  the  natural  history  of  the  disease  it  appears  that  attacks 
of  acute  appendicitis  may  subside  and  may  recur.  If  the  obliterative 
process  does  not  destroy  the  organ,  it  leaves  it  in  a  condition  favorable 
for  subsequent  attacks,  and  experience  teaches  that  subsequent  attacks 
are  common — indeed,  that  is  the  usual  history  of  our  cases.  The 
surgeon,  on  being  called  to  see  a  case  of  acute  appendicitis,  frequently 
learns  that  this  is  not  the  first  attack,  but  however  that  may  be,  the 

1  See  McCosh,  Appendicitis  in  Children,  Jour.  Amer.  Med.  Assoc,  September  24, 
1904;  and  Beth  Vincent,  Boston  Med.  and  Surg.  Jour.,  October  1,  1908. 


26  THE    ABDOMEN 

condition  found  does  not  vary  from  those  acute  attacks  already 
described. 

The  propriety  of  the  term  chronic  appendicitis  has  been  questioned, 
and  surgeons  have  asserted  that  such  a  disease  does  not  exist,  but  that 
recurring  or  relapsing  appendicitis  is  the  proper  term.  On  the  contrary-, 
it  appears  that  the  term  chronic  appendicitis  is  a  proper  one,  because 
definite  chronic  trains  of  symptoms  are  found  in  many  cases,  and  such 
symptoms  are  associated  with  definite  pathologic  changes  in  and  about 
the  appendix.  One  finds  injection  and  thickening  of  the  whole  organ, 
cicatrices,  kinks,  and  adhesions,  which,  though  unassociated  with  an 
active  inflammatory  process,  do,  by  their  constant  presence,  set  up 
annoying  or  grave  symptoms,  while  at  any  time  these  symptoms  may 
be  aggravated  or  rendered  alarming  by  a  supervening  acute  attack. 

An  important  practical  reason  for  using  the  term  chronic  appendicitis 
is  for  the  education  of  the  community,  and  I  urge  students  and  prac- 
titioners, when  discussing  appendicitis  with  patients  and  their  friends,  to 
insist  constantly  upon  the  clinical  distinction  between  acute  appendicitis 
and  chronic  appendicitis.  The  community  appreciates  in  a  general  way 
that  operations  for  chronic  appendicitis,  or  "between  attacks,"  are  far 
less  grave  than  operations  for  acute  appendicitis;  nevertheless,  the  word 
"appendicitis"  and  the  word  "operation"  are  sounds  of  dread.  The 
whole  subject  is  terrifying,  and  often  needlessly  so. 

SYMPTOMS  OF  APPENDICITIS 

As  for  the  symptoms  of  appendicitis,  it  is  well  to  divide  the  subject 
into  several  headings:  1.  Symptoms  of  acute  appendicitis  when  the 
inflammation  is  still  confined  to  the  aiDpendix.  2.  Symptoms  of  acute 
appendicitis  which  has  perforated  and  involved  neighboring  structures — 
periappendicular  tumor  and  abscess  formation.  3.  Appendicitis  caus- 
ing diffuse  peritonitis  and  other  complications.  4.  Symptoms  of  chronic 
appendicitis. 

The  first,  most  important,  and  omnipresent  sj'mptom  of  acute 
appendicitis  is  pain — often  agonizing  pain.  In  his  important  review 
of  2000  cases  Murphy  states  that  "pain  is  a  constant  and  uniform 
symptom,  and  was  not  absent  as  an  initial  symptom  in  this  series  of  2000 
cases. "^  This  initial  pain  rarely  is  definitely  localized.  It  may  be 
general  over  the  abdomen.  Frequently  it  is  referred  to  the  epigas- 
trium. Often  the  patient  holds  himself  rigid  and  dreads  palpation. 
Such  disseminated  pain  is  reflex,  for  we  recall  that  the  nervous  mechan- 
ism of  the  appendix  is  shared  with  the  stomach  and  small  intestine. 
The  initial  pain  is  due  to  obstruction  and  distention  of  the  lumen  of  the 
appendix.  While  the  pain  is  present,  one  may  feel  confident  that  the 
disease  is  still  strictly  within  the  appendix.  This  severe  pain  is  usually 
transient,  and  reaches  its  height  in  about  four  hours  from  its  onset; 
by  that  time  it  becomes  localized  in  the  right  iliac  fossa;  after  this  it 
subsides  gradually,  if  all  goes  well,  for  the  exudate  is  absorbed,  or 
1  John  B.  Murphy,  Amer.  Jour.  Med.  Sci.,  August,  1904. 


SYMPTOMS   OF   APPENDICITIS  27 

slowly  released  into  the  cecum,  and  by  the  end  of  thirty-six  hours 
the  pain  may  have  subsided  entirel}-,  in  which  case  one  may  regard  the 
attack  as  over  and  may  look  for  convalescence.  Probably  75  per  cent. 
of  the  attacks  of  appendicitis  are  of  this  nature  and  run  this  course  to 
spontaneous  recovery.  However,  if  within  thirty-six  hours  pain  is 
relieved  suddenly — that  is  a  danger-signal.  It  may  mean  escape  into 
the  cecum  of  an  obstructing  body,  but  more  often  it  means  perforation — 
rupture  of  the  appendix  or  complete  gangrene  of  that  organ. 

Nausea  and  vomiting  follow  pain  in  acute  appendicitis.  If  they 
precede  pain,  one  questions  the  diagnosis  of  appendicitis  and  looks  for 
some  such  condition  as  acute  gastritis.  The  nausea  and  vomiting  in 
acute  appendicitis  are  reflex  also.  The  primary  nausea  usually  subsides 
shortly. 

Tenderness  in  the  region  of  the  appendix  practically  always  is  pres- 
ent in  acute  attacks.  Usually  it  is  somewhat  diffuse,  but  often  it  is 
located  at  a  definite  point — sometimes  at  the  umbilicus,  but  more  com- 
monly at  what  is  known  as  McBurney's  point — in  a  line  drawn  between 
the  anterior-superior  spine  of  the  ilium  and  the  umbilicus,  about  1^ 
inches  from  the  anterior  spine. ^ 

Other  symptoms  and  signs  are  a  flushed  and  anxious  face;  slight 
general  distention  of  the  abdomen;  the  right  thigh  held  flexed  so  as  to 
relax  the  iliopsoas  muscle,  which  underlies  the  appendix;  a  moderate 
elevation  of  temperature,  sometimes  preceded  by  a  chill,  and  a  variable 
pulse,  ranging  between  80  and  100.  The  condition  of  the  bowels  is  not 
particularly  significant :  usually  there  is  constipation.  During  this  acute 
attack  careful  palpation  will  elicit  not  only  tenderness,  but  often  the 
enlarged  appendix,  which  may  be  easily  palpable  in  thin  subjects.  It 
is  my  habit,  if  the  patient  is  seen  early  and  the  condition  is  obscure, 
gently  to  pass  my  hands,  previously  wet  in  warm  water,  over  the  whole 
abdomen.  The  greater  part  of  this  surface  may  be  handled  with  com- 
parative freedom,  but  upon  approaching  the  right  iliac  fossa  resistance 
and  discomfort  pointing  to  a  local  trouble  are  experienced  by  the  patient. 
Another  useful  maneuver  is  slightly  to  irritate  the  skin  b}"-  gently  pinch- 
ing the  surface  of  the  abdomen,  when  the  skin  in  the  appendix  region 
is  found  more  sensitive  than  that  elsew^here. 

An  important  feature  of  the  examination,  never  to  be  neglected,  is 
exploration  of  the  rectum.  Very  often  the  patient,  when  thus  exam- 
ined, will  experience  a  sensation  of  sharp  localized  pain  high  in  the 
rectum,  even  though  the  finger  discover  nothing  abnormal.  You  must 
satisfy  yourself  that  the  expression  of  pain  is  not  clue  to  alarm  or  to  the 
discomfort  of  a  stretched  sphincter. 

In  the  early  stages  of  appendicitis  the  range  of  pulse  and  tempera- 
ture is  of  little  significance,  though  a  mounting  pulse  means  more  than 
does  a  high  temperature.  At  this  early  time  also  the  leukocj^te  count 
has  little  bearing  on  the  situation.  It  is  usually  slightly  elevated — • 
10,000,  12,000,  or  even  15,000  "whites";  but  it  is  significant  only  when 

1  For  an  interesting  discussion  of  McBurney's  and  (Robert  T.)  Morris's  points 
see  Jour.  Amer.  Med.  Assoc,  January  25,  1908,  p.  278. 


28  THE   ABDOMEN 

mounting  steadily  and  associated  with  other  symptoms  and  signs.  A 
sudden  drop  of  the  temperature  to  normal,  especially  when  associated 
with  a  rise  of  pulse,  means  trouble,  and  indicates  probable  perforation  of 
the  appendix,  with  a  temporary  cessation  of  septic  absorption.  If  all 
goes  well  and  the  inflammation  subsides,  convalescence  may  be  short 
and  the  jiatient  ma}-  regard  himself  as  sound  again  in  the  course  of  a  few 
days  or  of  a  week  at  the  most;  but  the  physician  must  bear  in  mind  the 
probability  of  a  subsequent  attack,  and  must  take  his  measures  and 
warn  his  patient  accordingly. 

Appendicitis  with  Periappendicular  Involvement. — In  a  con- 
siderable number  of  cases,  and  these  are  the  ones  which  try  the  nerves 
and  call  for  the  best  surgical  judgment,  appendicitis  does  not  subside 
quickly,  but  progresses  to  the  involvement  of  other  structures.  After 
the  initial  disturbance  which  I  have  described  the  pain  may  decrease 
in  a  measure,  tenderness  may  be  somewhat  less  acute,  nausea  may  cease, 
and  pulse  and  temperature  may  show  a  slight  drop;  but  convalescence 
does  not  proceed.  Pain  remains  localized  in  the  right  iliac  fossa;  slight 
nausea  may  persist,  as  well  as  abdominal  distention;  obstinate  constipa- 
tion ensues.  Gradually  the  temperature  may  rise  in  a  somewhat 
typhoidal  fashion.  The  pulse  mounts  to  100,  110,  120,  and  higher. 
Leukocytosis  increases.  Frequently,  vomiting  may  supervene.  A 
mass  may  become  evident  in  the  appendix  region — at  first  obscure  and 
perhaps  covered  b}'  distended  bowel;  later,  more  clearly  diffused, 
generally  resistant,  rarely  fluctuant,  definitely  outlined,  exquisitely 
tender.  The  finger  in  the  rectum  may  encounter  boggy  tissues  or  dis- 
tinct fluctuation.  The  right  side  of  the  abdomen  is  held  rigid,  and  it 
may  be  almost  board-like,  while  on  slightly  irritating  the  skin  a  charac- 
teristic spasm  of  the  right  rectus  is  seen;  localized  edema  of  the  skin 
appears.  Sometimes  the  tenderness  reaches  into  the  flank,  and,  if  the 
appendix  be  retrocecal,  acute  tenderness  and  fullness  even  may  be  found 
in  the  lumbar  region. 

These  signs  and  symptoms  indicate  a  progressive  infection,  an  in- 
volvement of  the  peritoneum  with  a  serous,  a  serofibrinous,  or  fibrino- 
purulent  exudate.  Happily,  adhesions  are  forming,  a  matting  of  intes- 
tines and  omentum  is  taking  place,  and  pus  is  collecting  in  the  inter- 
stices. In  such  cases  again  one  may  not  foretell  the  outcome;  but  the 
conditions  present  have  already  been  described  sufficiently  in  our  con- 
sideration of  the  pathologic  anatomy. 

Termination  in  Diffuse  Peritonitis  and  Other  Complications. 
— If  resolution  does  not  take  place,  the  clinical  picture  becomes  more  and 
more  alarming;  the  patient's  face  continues  flushed  and  anxious;  frequent 
persistent  vomiting  ensues,  with  straining  and  retching:  there  is  absolute 
constipation;  the  temperature  continues  high,  with  slight,  if  any, 
remissions ;  the  pulse  is  full  and  rapid ;  the  leukocyte  count  may  drop  at 
first,  and  later  may  rise  to  30,000,  40,000,  or  more;  the  whole  abdomen 
becomes  rigid ;  its  distention  increases ;  it  is  every^where  tender,  especially 
in  the  appendix  region;  the  normal  ballooning  of  the  rectum  may  become 
obliterated;  the  urine  is  high  colored,  often  loaded  with  albumin  and 


SYMPTOMS    OF   APPENDICITIS  29 

casts,  and  is  passed  in  small  amounts;  the  normal  sounds  of  peristalsis 
cannot  be  heard  with  the  stethoscope;  Peters,  a  Canadian  writer,  has 
called  attention  to  the  "telephonic  properties  of  the  inflamed  abdomen 
in  peritonitis" — the  distended  coils  of  intestine  pressing  against  the 
diajihragm  transmit  the  heart-sounds,  so  that  they  may  often  be  heard 
low  do^^•n  in  the  abdomen.^  I  have  often  found  this  sign  striking  and 
significant.  The  vomit,  at  first  bile-stained,  becomes  more  and  more 
offensive  as  intestinal  contents  are  returned  into  the  stomach.^  Such 
is  the  picture  of  an  intense  diffuse  peritonitis  resulting  from  appendicitis. 

Even  though  peritonitis  does  not  supervene,  other  grave  complica- 
tions may  ensue,  resulting  in  pyemia.  Abscesses  may  make  their  way 
in  various  directions,  as  has  been  pointed  out,  and  there  are  those  rare 
cases  of  the  rupture  of  an  abscess  into  a  vein,  producing  suppurative 
thrombosis.  Sometimes  an  abscess  may  become  surrounded  by  a  mass 
of  cicatricial  tissue,  so  that  the  condition  suggests  actinomycosis; 
but  the  general  condition  of  such  patients  rapidly  deteriorates,  and  the 
symptoms  are  more  grave  than  commonly  is  seen  in  a  localized  actino- 
mycosis. 

The  nature  of  the  infecting  organisms  in  acute  appendicitis  seems  to 
have  a  bearing  upon  the  progress  of  the  disease  and  upon  the  clinical 
picture.  If  staphylococci  be  the  offenders,  the  resulting  exudate 
checks  immediate  systemic  absorption  of  poison,  and  protects  the  patient 
against  an  overdose  of  the  septic  products.  "When  the  exudate  loosens, 
rapid  absorption  and  sudden  collapse,  with  diarrhea  and  an  anxious 
expression,  soon  followed  by  death,  are  apt  to  occur.  If  we  are  dealing 
with  streptococci  and  their  invasion  of  the  peritoneum,  there  ensue  rapid 
blistering  of  that  membrane,  a  high  pulse,  and  active  delirium;  and,  on 
the  other  hand,  the  colon  bacillus  may  produce  but  slight  local  irritation 
and  a  moderate  fever.  The  progress  of  the  coli  commune  infection  is 
slow,  generalh\  In  infection  by  staphylococci  there  is  little  pus  in  the 
peritoneal  cavity  usually,  but  when  there  is  a  large  amount,  it  is  of  the 
seropurulent  t3'pe.  In  the  case  of  streptococci  there  is  little  if  an}-  free 
pus,  but  the  peritoneum  has  a  peculiar  dry,  granulated,  blistered  ap- 
pearance. Colon  bacilli  produce  a  copious,  offensive  pus,  thick  and 
creamj'. 

The  profound  collapse  which  is  seen  in  the  cases  of  diffuse  peritoni- 
tis does  not  mean  recent  perforation,  but  indicates  advancing  septic 
absorption,  and  occurs  late  in  the  course  of  the  disease. 

The  symptoms  of  w^hat  is  called  chronic  appendicitis  are  more 
elusive  than  are  those  of  acute  appendicitis,  but  we  are  coming  to 
recognize  the  condition  as  far  more  common  than  was  supposed  at  one 
time.  You  must  note  the  distinction  between  chronic  appendicitis 
and  relapsing  appendicitis,  in  the  sense  in  which  we  are  coming  to  use 
the  terms.  Relapsing  appendicitis  signifies  a  series  of  acute  attacks  of 
appendicitis  following  one   another   at  var3'ing  intervals,   while  each 

1  Canadian  Jour.  Med.  and  Surg.,  December,  1902,  p.  420. 

2  So-called  "fecal  vomitus"  is  usually  the  secretion  of  the  small  intestine  mixed 
with  altered  blood. 


30  THE    ABDOMEN 

attack  may  bo  grave.  The  liability  to  nH-unvnce  in  acute  appendicitis 
has  long  been  recognized,  and  writers  estimate  variously  that  liability, 
Fitz  placing  it  at  44  per  cent,  of  all  cases;  Hawkins,  at  23.0  per  cent., 
and  other  writers  as  high  even  as  60  per  cent.  By  chronic  appendicitis 
I  mean  a  condition  which  is  not  necessarily  associated  with  acute  attacks. 
A  case  from  my  list  will  illustrate  what  is  meant.  Some  years  ago  there 
came  under  my  care  a  college  student,  twenty-one  years  of  age.  He 
was  a  robust,  well-developed,  athletic  young  fellow,  a  foot-ball  player, 
of  excellent  habits  and  wholesome  mode  of  life.  Three  years  before  I 
saw  him  he  was  supposed  by  his  physician  to  have  contracted  malaria. 
Every  six  or  eight  weeks  he  had,  for  four  or  five  days,  attacks  of  malaise, 
with  headache,  slight  pyrexia,  occasional  nausea,  and  general  al^xloniinal 
discomfort.  Betw^een  these  attacks  he  regarded  himself  as  well,  but  he 
confessed  to  a  delicacy  of  digestion — hearty  meals  distressed  him — 
and  an  irregularity  of  the  bowels,  with  alternating  periods  of  constipa- 
tion and  diarrhea.  These  conditions  had  continued  without  special 
change.  The  young  man  had  sought  various  advice;  had  traveled  in 
search  of  health,  and  had  lived  in  sundry  places.  Finally,  during  one  of 
his  remissions  he  happened  to  consult  me,  when,  on  making  a  careful 
abdominal  examination,  I  made  out  repeatedly  a  sensitive,  not  painful, 
point  in  the  right  iliac  fossa.  Convinced  that  his  appendix  was  at  fault, 
even  if  it  was  not  the  source  of  the  trouble,  I  removed  it.  The  patient's 
recovery  of  health  was  prompt  and  permanent. 

Such  an  example  is  not  typical  of  all  cases  of  chronic  ai)pendicitis, 
but  it  suggests  the  sort  of  cases  we  are  discussing.  In  general  terms 
patients  with  chronic  appendicitis  complain  of  more  or  less  dyspepsia 
and  general  poor  health,  without  very  definite  symptoms  except  that 
the  disturbance  is  abdominal.  Rarely  do  they  give  a  history  of  an  acute 
attack  of  appendicitis.  Acute  attacks  are  more  likely  to  be  followed  by 
acute  attacks.  The  chronic  condition  is  found  frecjuently  in  chiklren,  as 
well  as  in  adults,  and  accumulating  experience  has  convinced  us  that  the 
group  chronic  appendicitis  is  far  larger  than  most  physicians  and  the 
writers  of  text-books  are  disposed  to  think. 

DIAGNOSIS  OF   APPENDICITIS 

In  the  diagnosis  sundry  conditions  simulating  appendicitis  must  be 
borne  in  mind.  Whenever  confronted  with  a  case  of  abdominal  disease, 
try  first  to  rule  out  appendicitis.  A  common  and  serious  error  is  the 
confounding  a  perforating  duodenal  or  gastric  ulcer  with  appendicitis. 
A  duodenal  ulcer  breaks  through  into  the  abdominal  cavity,  pouring 
out  intestinal  contents  into  the  right  flank,  over  the  kidney,  and  dovm 
into  the  appendix  region.  Symptoms  suggestive  of  appendicitis 
may  arise  immediately.  Whichever  condition  is  present,  however, 
prompt  operation  is  indicated,  so  that  in  the  hands  of  an  intelligent 
surgeon  no  time  is  lost.  Typhoid  fever  has  been  mistaken  for  appendi- 
citis, and  often  the  differentiation  is  difficult.  In  many  cases  of  appendi- 
citis one  must  bear  in  mind  the  symptoms  of  typhoid,  especially  the 


TREATMENT   OF   APPENDICITIS  31 

character  of  the  temperature  and  stools,  the  prodromata,  the  gradual 
onset,  the  enlarged  spleen,  the  rose  spots,  and  the  reaction  to  Widal's 
test.  Rarely,  a  tj-phoid  ulcer  may  be  located  in  the  appendix,  and 
writers  estimate  that  about  5  per  cent,  of  all  typhoid  perforations  are 
appendiceal.  Then  there  are  actinomycosis  and  tuberculosis — chronic 
processes,  but  sometimes  impossible  to  determine  before  operation. 
Other  diseases — inflammation  of  the  gall-bladder  and  ducts,  renal 
calculus,  mesenteric  thrombosis,  inflammation  of  a  Meckel's  diverticu- 
lum, cancer,  inguinal  adenitis,  intestinal  obstruction  from  fecal  impac- 
tion— all  must  be  remembered,  and  usually  are  easily  distinguished,  with 
the  exception  of  mesenteric  thrombosis  and  disease  of  Meckel's  diver- 
ticulum. In  women,  too,  we  must  think  of  diseases  of  the  right  ovary 
and  tube. 

When  we  see  a  patient  who  gives  the  history  of  sudden,  prostrating 
abdominal  pain,  nausea  and  vomiting,  with  constipation,  with  disten- 
tion, with  right-sided  rigidity,  with  high  rectal  tenderness,  spasm  of  the 
right  rectus,  tenderness  in  the  right  iliac  fossa,  a  rising  temperature 
and  pulse,  and  a  leukocytosis  of  10,000  and  upward,  we  are  safe  in  con- 
cluding that  here  is  a  case  of  acute  appendicitis,  though  we  must  remem- 
ber always  that  all  these  symptoms  are  not  constantlj^  present  in  that 
disease.  Above  all  things,  never  forget  that  an  obscure,  obstinate,  and 
acute  abdominal  distemper,  suggestive  of  sundry  diverse  diseases,  is 
appendicitis  on  the  chances,  and  in  a  great  majority  of  cases. 

A  discussion  of  the  prognosis  of  appendicitis  is  profitless,  because 
of  the  varying  types  of  the  disease,  and  because,  more  than  any  other 
surgical  lesion,  appendicitis  lends  itself  to  surgical  treatment.  We  have 
seen  that  a  majority  of  acute  cases  recover  spontaneously,  though  a 
large  proportion  of  them  are  subject  to  relapses,  and  no  man  may  say 
which  will  relapse  and  which  will  remain  well. 

TREATMENT  OF  APPENDICITIS 

The  treatment  of  acute  appendicitis  has  been  made  a  subject 
of  infinite  variety.  It  should  be  almost  a  matter  of  routine.  Like  the 
offending  eye  in  the  parable,  the  inflamed  appendix  should  be  cut  out 
and  cast  away.  Yet  so  various  are  the  symptoms  of  appendicitis,  so 
confusing  often  are  they,  and  so  manifold  are  men's  points  of  view,  that 
it  seems  as  though  this  discussion  of  treatment  may  be  prolonged  through 
the  ages.  In  many  cases  patients  recover  spontaneously.  That  is  the 
hub  of  the  situation;  and  because  many  cases  recover  spontaneously, 
therefore  certain  men  say,  "any  case  may  recover  spontaneously,  so 
let  us  wait."  In  contracHstinction  to  this  opinion,  which  recognizes 
an  immediate  mortality  of  at  least  20  per  cent.,  it  is  weU  to  balance  the 
fact  that  if  we  operate  upon  all  cases  of  appendicitis,  we  shaU  have  a 
mortahty  of  5  per  cent.^  Divergence  of  opinion  on  this  matter  is  more 
accentuated  now  than  it  was  twenty  years  ago.     Twenty  years  ago  a 

1  John  B.  Deaver,  Factors  in  the  Mortality  of  Appendicitis,  Jour.  Amer.  Med. 
Assoc,  September  24,  1904. 


32  THE    ABDOMEN 

large  majority  of  physicians  and  surgeons  believed  that  we  should  delay 
operation,  should  wait  until  an  abscess  was  ''  ripe/'  and  should  then  open 
it  under  the  most  favorable  conditions.  This  was  called  the  conserva- 
tive method,  and  ph}'sicians  were  wont  to  watch  the  case  until,  in  their 
opinion,  it  was  time  for  operation,  when  they  called  the  surgeon.  Grad- 
ually, the  scales  have  been  reversed.  No  sane  practitioner  now  regards 
appendicitis  as  a  "medical  disease"  to  which  a  surgeon  occasionally 
may  be  called.  It  is  a  surgical  disease  as  much  as  is  a  br-oken  leg,  and 
the  surgeon  should  be  calletl  as  soon  as  appendicitis  is  suspected.  The 
practitioner  must  not  wait  to  make  the  diagnosis.  He  must  call  the 
surgeon  to  do  that.  He  must  call  the  surgeon  to  determine  the  cause  of 
every  acute  abdominal  pain  such  as  I  have  described  in  this  chapter. 

As  a  knowledge  of  appendicitis  developed  we  came  to  see  that  opera- 
tive measures  must  be  applied  early  and  thoroughly ;  but  there  has  always 
been  a  certain  number  of  men  who  opposed  this  view.  Numerous  modes 
of  treatment  have  found  favor,  among  the  advocates  of  delay,  such 
methods  as  the  use  of  opium  and  ice,  on  the  one  hand,  of  saline  purges 
and  poultices,  on  the  other.  Happily,  such  treatment  is  now  relegated 
by  the  best  practice  to  the  limbo  of  a  contemptuous  oblivion;  but  in 
spite  of  strenuous  years  of  missionary  work,  we  find  bad  practices  still 
pursued  in  many  communities.  Setting  aside  a  consideration  of 
antiquated  and  improper  procedures,  we  find  that  there  is  still  a  division 
of  opinion  among  competent  surgeons  as  to  the  wisdom  of  operating 
always  and  in  early  stages  of  acute  appendicitis.  There  is  still  debate 
upon  the  question  whether  or  not  to  operate  at  once  in  the  second  stage 
of  appendicitis — in  that  stage  when  periappendiceal  tissues  are  beginning 
to  be  involved,  and  when  adhesions  of  strength  sufficient  to  confine  the 
process  have  not  yet  been  formed.  In  the  vast  majority  of  cases,  how- 
ever, all  competent  surgeons  are  agreed  that  immediate  operation 
is  necessary.     Let  us  now  consider  briefly  the  early  operation. 

We  have  seen  how  appendicitis  usually  starts;  how,  commonly, 
the  process  is  at  first  confined  to  the  appendix,  and  we  know  that  no 
man  may  say  at  the  outset  what  the  course  of  the  disease  will  be. 
Therefore,  at  the  outset,  open  the  abdomen  and  remove  the  appendix — 
and  we  understand  by  outset,  within  the  first  twenty-four  or  thirt3"-six 
hours. 

Early  Appendectomy. — There  are  two  excellent  methods,  among 
others,  of  reaching  the  appendix — the  McBurney  method  and  the 
retromuscular,  sometimes  called  Battle's  method.  The  McBumey 
method  was  devised  by  that  surgeon  some  sixteen  years  ago.^  Its 
purpose  is  a  muscle-splitting,  not  a  cutting,  operation,  so  that  practically 
structures  are  not  damaged,  and,  especially,  nerves  and  aponeuroses 
remain  intact.^  The  skin  is  incised  obliquely  for  3  or  4  inches, 
over  the  usual  seat  of  the  appendix.     The  aponeurosis  of  the  external 

1  Ann.  Surg.,  1894,  vol.  xx,  p.  38. 

2  When  possible,  employ  the  McBurney  method  below,  or  on  a  level  with,  the 
anterior  iliac  spine.  The  lower  tlie  opening,  the  wider  and  freer  can  it  be  made. 
This  low  opening,  "the  low  McBurney,"  is  my  operation  of  choice  in  all  appendix 
operations. 


TREATMENT   OF   APPENDICITIS 


33 


oblique  is  reached  and  split  longitudinally.  The  parts  are  drawn  aside 
with  narrow  retractors,  exposing  the  internal  oblique,  running  at  an  angle 
with  the  previous  incision.  In  its  turn  this  is  split,  and  the  underlying 
trunsversalis  is  treated  in  the  same  fashion.  Then  the  peritoneum  is 
opened,  the  finger  is  introduced,  and  the  cecum  is  drawn  to  the  surface.  In 


A-S4.     X  1 


TRAriSVCKifiLtd 


Fig.  8. — McBurney's  operation  (high). 

Battle's  method  the  abdomen  is  opened  through  the  sheath  of  the  rectus. 
The  uncut  rectus  is  drawn  inward,  and  the  peritoneum  behind  it  is 
incised.  In  closing  the  wound  the  muscle  falls  back  into  place  without 
stitching.  The  peritoneum  and  anterior  sheath  alone  are  sutured. 
These  maneuvers  are  facilitated  by  tipping  the  patient  into  the  Trendel- 


Fig.  9. — McBurney's  operation  (low). 

enburg  position — that  is,  inverting  the  body  so  that  the  pelvis  lies  at  an 
angle  of  from  30  to  45  degrees  above  the  shoulders.  The  cecum  is 
drawn  outside  the  wound,  and  the  appendix  is  delivered.  Usually  it 
is  easy  at  this  stage  to  find  the  appendix,  for  it  is  swollen  and  readily 
palpable  and  pops  out  at  once.  If  it  is  not  quickly  discovered,  the  best 
guides  to  it  are  the  longitudinal  bands  of  the  cecum,  which  converge 

3 


34 


THE   ABDOMEN 


at  the  appendix  immediately  below  and  behind  the  ileocecal  valve.* 
Remove  the  appendix  by  clamp,  ligature,  and  cautery,  as  follows: 
Compress  the  organ  close  to  the  cecum  with  a  stout  pair  of  hemostats; 
then  remove  the  hemostats  and  apply  firmly  a  stout  catgut  ligature  in 
the  crushed  line.  Clean  away  toward  the  tip  of  the  appendix  the  con- 
tained fluid  for  a  short  distance  from  the  ligature,  and  again  grasp  the 


Fig.  10. — McBurney's  operation  (low). 

appendix  with  hemostats  about  J  inch  from  the  ligature.  Cut  away 
with  the  actual  cautery  the  appendix,  between  the  ligature  and  the 
hemostats.^  Drop  back  into  the  abdomen  the  cecum  with  the  appendix 
stump,  and  follow  it  down  with  a  gauze  wick  which  must  be  left  in  place 
as  a  drain.  Do  not  leave  the  stump  undrained,  and  do  not  sew  up  the 
wound.     I  believe  sewing  up  to  be  a  dangerous  procedure;  nothing 


-^9?, 


Fig.  11. — Diagram  showing  delivery  of  cecum. 

is  gained  in  time  or  strength  of  scar  by  so  doing,  and  no  man  may  say 
that  a  nidus  of  infection  does  not  remain  which,  if  left  undrained,  will 
lead  to  disastrous  results.  If  all  goes  well  with  the  drained  case,  the 
wick  may  be  removed  at  the  end  of  forty-eight  hours,  the  tissues  will 
fall  together,  the  external  oblique  aponeurosis  and  the  skin  may  be 

^  Note  Hough's  peritoneal  band,  running  from  the  anterior  iliac  spine  to  the 
cecum  at  the  base  of  the  appendix. 

2  I  shall  mention  later  the  debated  question  of  treatment  of  the  appendix  stump. 


TREATMENT   OF   APPENDICITIS  35 

stitched  if  one  chooses,  and  convalescence  will  progress  without  disturb- 
ance and  without  resulting  hernia. 

In  the  after-treatment  of  these  early  cases  three  factors  are  to  be  ob- 
served :  rest,  feeding,  care  of  the  bowels.  The  patient  should  be  kept  in  bed 
for  at  least  twelve  days ;  he  should  then  begin  to  sit  up  a  little  every  day, 
and  by  the  end  of  three  weeks  he  should  be  walking  about.  He  should 
wear  a  stout  abdominal  binder  for  a  month  after  the  operation.  This 
relieves  occasional  discomfort  and  provides  support  to  facilitate  the  firm 
healing  of  the  scar.  In  most  cases,  after  two  months,  patients  may 
turn  to  active  exercise.  For  the  first  twenty-four  hours  after  the  opera- 
tion the  patient  should  be  starved,  and  allowed  water  only.  For  the 
second  twenty-four  hours  he  may  have  clear  soups  and  broths.  After 
that  a  gradually  increasing  diet,  until,  at  the  end  of  five  days,  he  is 
eating  regularly.  The  care  of  the  bowels  is  a  debated  question.  They 
might  be  left  alone,  waiting  upon  nature's  prompting,  except  for  a  ten- 
dency to  meteorism,  sometimes  associated  with  severe  pain.  One  should 
remember,  however,  that  most  of  these  patients  are  emergency  cases 
and  come  to  the  operating  table  with  bowels  more  or  less  loaded.  My 
practice,  therefore,  is  to  give  the  patient  a  high  glycerin  enema  twenty- 
four  hours  after  the  operation,  and  at  the  end  of  thirty-six  hours  to  clean 
out  the  bowels  from  above  with  calomel  and  salines.^  This  practice  is 
not  invariable.  In  many  cases  it  must  be  altered;  when  distention  and 
pain  are  marked,  high  enemata  and  the  rectal  tube  may  be  used  soon 
after  the  recovery  from  ether.  Furthermore,  it  is  sometimes  advisable 
to  employ  calomel  immediately  on  the  subsidence  of  ether  nausea. 

The  reader  will  see  that  such  dealing  with  acute  appendicitis  in  the 
early  stage  does  not  differ  materially  from  our  treatment  of  the  appendix 
"in  the  interval,"  as  I  shall  explain  later. 

Discussion  rages  about  the  question  of  operating  upon  cases  in  which 
the  inflammation  has  spread  beyond  the  appendix.  The  weight  of 
authority  directs  that  we  operate  at  once  even  in  this  stage.  Objections 
to  such  operating  have  been  urged  by  certain  well-known  writers, 
dealing  with  certain  stages  of  periappendicular  inflammations,  and 
their  sentiments  found  able  voice  through  A.  J.  Ochsner  at  the  Saratoga 
meeting  of  the  American  Medical  Association  in  1904.^  He  pointed  out 
that  the  mortality  in  appendicitis  results  from  the  extension  of  infection 
from  the  appendix  to  the  peritoneum,  or  from  metastatic  infection  from 
the  same  source;  that  the  distribution  of  the  infection  is  accompHshed 
by  the  peristaltic  actions  of  the  small  intestines,  and  that  it  is  also 
accomplished  by  operation  after  the  infectious  material  has  extended 
beyond  the  appendix,  and  before  it  has  become  circumscribed.  Accord- 
ingly, in  certain  of  these  cases  it  is  advised  that  operation  be  delayed 
until  strong  adhesions  are  formed,  and  in  general  terms  the  time  limit 
for  such  delay  is  from  thirty-six  hours  from  the  onset  of  the  disease  until 

1  Calomel,  \  grain  every  hour  for  four  doses;  a  Seidlitz  powder  one-half  hour  after 
the  last  dose  of  calomel,  and  a  low  suds  enema  when  the  desire  for  a  movement  is  felt. 

2  Ochsner  made  a  first  detailed  statement  at  the  meeting  of  the  American  Medical 
Association  in  1903.     See  Jour.  Amer.  Med.  Assoc. 


36  THE   ABDOMEN 

about  the  fifth  day  or  later,  if  the  process  is  obviously  subsiding.  To 
accomplish  rest  and  to  give  nature  an  opportunity  to  wall  off  the  disease 
it  is  directed  that  every  form  of  nourishment  and  cathartics  by  mouth 
be  prohibited,  and  that  gastric  lavage  be  employed  in  oi'der  to  remove 
any  food  or  mucus  from  the  stomach.  Nutrition  is  to  be  maintained 
by  low  enemata.  Large  and  high  enemata  must  not  be  given.  It  is 
claimed,  and  apparently  is  proved  by  a  great  array  of  figures,  that  in  this 
way  cases  of  acute  a])pendicitis  may  be  changed  into  relatively  harmless 
cases  of  chronic  appendicitis,  and  that  the  mortality  may  be  greatly 
reduced.  In  spite  of  vigorous  criticism  by  a  majority  of  surgeons,  and 
skepticism  as  to  such  results,  there  is  no  doubt  that  the  treatment  above 
described,  which  has  come  to  be  known  as  the  "Ochsner  treatment," 
has  been  remarkably  successful  in  the  hands  of  its  author.  Surgeons 
claim,  however, — and  with  this  view  I  am  in  heartj^  sympathy, — that 
this  let-alone  treatment  is  dangerous  in  the  hands  of  the  general  practi- 
tioner who  attempts  to  carry  it  out  without  consulting  a  surgeon.  The 
disease  is  so  insidious,  its  changes,  progress,  and  recessions  are  so  rapid, 
complicated,  and  puzzling,  that  it  is  far  safer  to  consign  all  cases  imme- 
diately to  the  hands  of  an  experienced  operator.  If  his  experience  shall 
prompt  him  to  delay,  it  wdll  also  prompt  him  to  operate,  should  prolonged 
delay  appear  dangerous.  Though  the  Ochsner  figures  show  a  low 
mortality  and  a  brilliant  series  of  results,  so,  too,  do  the  figures  of 
competent  surgeons  who  operate  at  once  in  practically  all  cases.  J.  B. 
Deaver  is  a  strenuous  advocate  of  immediate  operation,^  and  his  statis- 
tics, showing  a  mortality  of  5  per  cent,  only,  can  hardly  be  improved 
upon.  If  the  operation  be  properly  done,  if  the  spreading  infection  be 
walled  off,  if  prolonged  effort  be  not  made  by  the  surgeon  when  searching 
for  the  appendix,  if  pockets  of  pus  be  sought  out  and  drained,  the  results 
will  be  favorable  in  a  vast  majority  of  cases. 

There  are,  however,  certain  conditions  under  which  all  men  are  agreed 
i;hat  operation  should  not  be  attempted;  it  may  be  impossible  to  secure 
a  competent  surgeon  for  the  given  case,  or  there  may  be  some  serious 
underlying  disease,  such  as  advanced  nephritis,  heart  disease,  diabetes, 
or  tuberculosis.  Operation  is  ill  advised  also  in  those  cases  of  diffuse 
peritonitis  in  which  the  abdomen  is  distended,  the  temperature  high, 
the  pulse  rapid  and  of  high  tension,  the  patient's  expn^ssion  anxious 
and  indicative  of  serious  intra-abdominal  infection,  the  bowels  consti- 
pated and  unable  to  cause  the  expulsion  of  flatus,  and  in  which  vomiting 
is  continuous  and  tenderness  is  diffuse  over  the  entire  abdominal  wall. 
Then  the  tongue  is  dry  and  brown,  the  skin  is  dry,  and  the  frequent 
delirium  is  shortly  followed  by  coma  and  death. 

"In  another  class  of  cases  the  features  are  pinched,  the  skin  cold  and 
clammy,  the  temperature  is  normal  or  subnormal,  the  pulse  rapid  and 
thready,  the  leukocytes  are  below  normal  in  numlier,  and  the  abdomen 
hard  and  rigid  throughout,  without  much  distention. "- 

Such  conditions  as  the  above  are  desperate.     Diffuse  and  rapidly 

1  J.  B.  Deaver,  Factors  in  the  Mortality  of  Appendicitis,  Jour.  Amer.  Med. 
Assoc,  September  24,  1904.  2  Deaver,  ibid. 


TREATMENT   OF   APPENDICITIS  37 

spreading  peritonitis  is  present,  and  the  patient  is  on  the  brink  of  dis- 
solution. Operation,  then,  is  practically  always  followed  by  death. 
If  it  does  seem  best  to  operate,  however,  in  order  to  relieve  distention  or 
in  the  hope  possibly  of  draining  septic  products,  one  should  be  satisfied 
with  making  an  incision  and  inserting  a  large  drainage-tube  without 
irrigation  and  without  sponging  or  manipulation  of  the  tissues. 

One  sees  from  the  above  statements  that  it  is  often  impossible 
clinically  to  determine  the  time  at  which  operation  is  wise  or  unwise 
in  an  advancing  infection.  Practically,  the  answer  to  the  question 
amounts  to  this,  that  so  long  as  the  patient's  general  condition  is  fair 
and  the  toxemia  is  not  extreme,  some  form  of  operation  is  indicated, 
whereas  in  the  face  of  a  profound  toxemia,  operation  must  be  futile 
except  for  the  relief  of  distention.  If  the  stage  favorable  for  operation 
has  not  yet  been  passed,  one  should  remove  the  appendix,  if  accessible, 
as  well  as  institute  drainage. 

Observe  that  in  discussing  the  advance  of  periappendicular  inflam- 
mations I  have  not  drawn  a  sharp  line  of  distinction  between  the  early 
progress  of  the  disease  and  advanced  diffuse  peritonitis.  I  have  not 
drawn  this  line  because  frequently  it  is  impossible  to  differentiate, 
and  because  one  may  find  within  the  abdomen  unexpected  conditions, 
quite  different  from  those  anticipated — sometimes  a  limited  inflamma- 
tion, when  a  diffuse  peritonitis  was  anticipated,  sometimes  an  unex- 
pected spreading  peritonitis.  Under  all  circumstances  the  surgeon  must 
be  guided  by  his  estimate  of  the  patient's  general  condition  and  capacity 
for  resisting  infection. 

Happily,  it  occurs  that  in  the  great  majority  of  cases  adhesions  do 
form,  so  that  the  progress  of  the  disease  is  checked  or  retarded,  and  a 
localized  inflammation  surrounded  by  sound  viscera  is  presented  to  the 
operator. 

The  method  of  dealing  with  a  localized  process— inflammatory 
adhesions,  exudate,  pus-pockets,  and  necrosis — is  as  follows:  Open 
the  abdomen  through  a  free  incision  somewhere  to  the  inner  side 
of  the  inflamed  mass — a  low  McBurney  incision  is  recommended; 
the  cut  should  be  long  enough — five,  six,  or  more  inches— to  admit 
of  free  manipulation  within  the  abdomen;^  recognize  by  gentle 
intra-abdominal  palpation  the  limits  of  the  mass,  and  wall  it  off  with 
gauze  wicks  before  proceeding  (Fig.  12).  Such  gauze  wicks  carefully 
and  deftly  introduced  into  the  pelvis,  to  the  inner  side  of  the  mass  and 
above  it,  limit  the  possible  damage  from  escaping  septic  material. 
Having  walled  off  the  intestines,  one  may  proceed  at  leisure.  Break 
up  adhesions  to  the  outer  side  of  the  mass,  explore  and  evacuate  pus- 
pockets,  seek  and  remove  the  appendix,  employing  catgut  figature  and 
cautery;  wipe  out  the  wound  carefully  with  gauze,  and  complete  the 
operation  by  appropriate  drainage — one  wick  to  the  appendix  stump, 

1  John  G.  Sheldon,  A  Posterior  Incision  in  Certain  Appendix  Operations,  Ann. 
Surg.,  September,  1904,  p.  376.  Sheldon  has  approached  the  disease  by  a  lumbar 
incision,  through  the  triangle  of  Petit.  Sheldon  has  operated  thus  on  about  60  cases, 
and  claims  for  his  method  the  advantage  of  perfect  drainage  and  no  chance  of  hernia. 


38 


THE    ABDOMEN 


and,  if  conditions  indicate  it,  two,  three,  or  more  wicks  for  walling-off 
purposes  and  for  the  drainage  of  separate  pus-pockets.  If  the  appendix 
has  sloughed  off  and  the  cecum  is  open,  drain  by  a  tube  the  cecum  at 
once,  as  in  the  operation  of  enterostomy,  thus  estabUshing  a  tem})orar)' 
fecal  fistula  and  guiding  intestinal  contents  away  from  the  deep  tissues. 
The  tube  (Fig.  13)  ma}-  be  withdrawn  in  a  few  days,  after  which  the 
fistula  usually  will  close  spontaneously.  In  the  after-treatment  of 
these  wide  appendicitis  wounds  far  more  care  and  attention  to  detail 
are  demanded  than  after  the  simple  early  operation.     In  the  compli- 


Fig.  12. — Appendix  under  cecum;  pregnant  uterus.     Note  walling  off  with  gauze. 


Gated  cases  the  abdominal  wall  must  not  be  stitched  up  closely,  though 
two  or  three  through-and-through  stitches  at  the  ends  of  the  wound  are 
allowable;  a  large  opening  must  be  left  for  free  drainage.  For  the  first 
day  or  two  exudate  escapes  copiously;  gradually  the  amount  diminishes, 
and  gradually  the  wicks  loosen.  B}-  the  end  of  five  days  or  a  week 
the  wicks  may  be  withdrawn  easily,  and  shorter,  fresh  ones  substituted. 
Do  not  draw  the  wicks  out  roughly  so  long  as  they  remain  adherent  to 
the  viscera.  Commonly,  the  wicks  are  all  out  and  the  wound  granulat- 
ing superficially  at  the  end  of  three  or  four  weeks.     A  weak  scar  results, 


TREATMENT   OF    APPENDICITIS 


39 


sometimes  subject  to  hernia,  of  which  the  patient  must  be  warned; 
and  sometimes  a  subsequent  operation  for  hernia  is  necessary.  The 
reg'uUition  of  the  bowels  and  of  the  diet  does  not  differ  materially  from 
that  already  described;  but  in  these  cases,  with  large  wounds,  con- 
valescence is  slow,  many  weeks  often  are  necessary  for  recuperation, 
and  the  use  of  an  abdominal  belt  for  five  or  six  months  may  be  im- 
portant. 

So  far  as  concerns  operating  in  cases  of  diffuse  and  spreading  peri- 
tonitis from  appendicitis,  I  do  not  recommend  the  multiple  incisions,  the 
wijDing  and  long-continued  washing  sometimes  advocated.     Open  the 


Fie;.  13. — Mixter  tube  in  cecum. 


abdomen  by  a  free  incision  on  the  right,  as  already  described,  secure  the 
appendix  if  it  is  easily  accessible  only,  introduce  into  the  pelvis  a  large 
fenestrated  cigaret  drain  or  split  rubber  tube,  and  provide  for  further 
tube-drainage  through  a  stab-wound  above  the  left  inguinal  ring.^  To 
relieve  excessive  and  paralyzing  intestinal  distention  puncture  the  bowel 
in  several  places  with  a  trocar,  and  draw  off  gas  and  Hquid  contents. 
I  have  seen  no  benefit  from  introducing  concentrated  epsom  salts 
through  the  trocar,  as  is  sometimes  advised. 

The  after-treatment  is  important,  and  the  practitioner  will  do  well 
to  follow  for  a  day  or  two  the  so-called  Ochsner  method — no  food  or  drink 

1  See  an  interesting  discussion  of  this  question  by  Lucius  W.  Hotchkiss  in  Med. 
News,  July  2,  1904. 


40  THE   ABDOMEN 

by  mouth,  gastric  lavage  if  vomiting  persists,  nutrient  enemata,  and  the 
use  of  copious  saline  injections,  preferably  by  the  "seeping  method" 
suggested  by  J.  B.  Murphy.^  In  both  diffuse  peritonitis  and  in  the 
simpler  circumscribed  cases  the  semi-u})right  posture  of  Fowler  is  valu- 
able for  promoting  drainage  and  limiting  the  spread  of  infection. 

There  are  numerous  other  nice  and  complicated  questions  which 
arise  in  the  discussion  of  appendicitis;  but  their  consideration  finds  no 
place  here  except  for  two  important  points:  (1)  In  the  case  of  appendicitis 
occurring  in  pregnant  women,  one  must  disregard  the  pregnancy  and 
operate.  Miscarriage  sometimes  follows,  but  that  is  an  inevitable  risk. 
(2)  When  operating  within  the  abdomen  for  some  other  lesion,  always 
investigate  the  appendix,  and  remove  it  if  it  is  involved,  or  if  there  is 
cause  to  suspect  that  it  may  become  involved  through  the  spread  of  a 
peritoneal  inflammation  antl  the  formation  about  it  of  adhesions. 

Operation  for  Relapsing  and  Chronic  Appendicitis. — Kocher 
says  that  this  operation  has  been  treasured  as  the  jewel  of  operative 
surgery.  So  easy  is  it,  and  so  far  reaching  are  its  benefits,  that  the 
question  often  has  been  raised,  should  not  the  appendix  be  removed 
whenever  the  abdomen  is  opened  for  any  purpose;  and  when  one  remem- 
bers that  a  majority  of  mankind,  first  and  last,  suffer  in  some  degree 
from  trouble  in  the  appendix,  this  proposition  does  not  sound  unreason- 
able. After  removal  of  the  crippled,  but  c[uiescent,  appendix,  94  per 
cent,  of  patients  make  a  prompt  and  complete  recovery,  and  the  remain- 
ing 6  per  cent.,  though  occasionally  troubled  by  painful  adhesions  and 
irritation  about  the  wound,  are  freed  entirely  from  the  dread  of  a  sub- 
sequent appendicitis.  The  mortality  in  these  operations  is  practically 
nil. 

The  technic  of  removing  the  quiescent  appendix  is  essentially  that 
of  removing  the  appendix  in  the  first  hours  of  inflammation,  though  in 
the  case  of  the  quiescent  appendix  the  skin  incision  may  be  very  small — 
from  one  to  two  inches  in  length.  The  approach  may  be  made  by  either 
the  high  or  low  McBurney  or  the  retromuscular  (Battle's)  route.  I 
prefer  the  "  low  McBurney  "  because  thus  the  opening  may  be  enlarged 
without  damage  to  structures.  Having  clamped  and  removed  the  ap- 
pendix, the  question  of  the  treatment  of  the  stump  has  agitated  sur- 
geons,^ but  experience  shows  that  sundry  methods  are  safe  and  applic- 
able. Some  operators  cut  off  the  undamped  appendix  close  to  the 
cecum  and  invert  and  stitch  up  the  resulting  hole ;  some  operators  ligate 
and  cut  off  the  appendix  and  bury  the  stump  by  sutures  in  the  wall  of 
the  cecum.  For  some  years  I  have  followed  the  practice  of  crushing 
and  ligating  the  stump  wath  catgut,  cauterizing  the  exposed  end, 
burying  it  in  the  stump  of  the  meso-appendix,  and  dropping  it  back 

1  The  method  of  allowing  saline  solution  to  seep  into  the  rectum  is  widely  ap- 
plicable in  these  cases,  which  demand  a  large  supply  of  water  for  tlie  exhausted 
tissues.  A  common  vaginal  nozzle  attached  to  a  fountain  syringe  is  introduced 
within  the  sphincter  ani.  The  reservoir  is  placed  about  8  inches  above  the  buttocks, 
and  the  solution,  constantly  kept  warm,  is  allowed  to  drift  through  the  tube.  Many 
pints  daily  may  thus  be  introduced  without  especial  discomfort. 

2  H.  A.  Kelly  in  Amer.  Med.,  December  31,  1904,  describes  what  he  calls  "the 
ideal  method." 


TREATMENT   OF    APPENDICITIS  41 

without  further  treatment.  This  method  has  been  satisfactory  in  many 
hundreds  of  cases.* 

The  httle  wound  in  the  abdominal  wall  may  be  secured  with  buried 
catgut  stitches  or  with  through-and-through  sutures.  It  makes  little 
difference  so  long  as  the  severed  aponeuroses  are  accurately  repaired. 
The  after-treatment  differs  in  no  essential  from  the  after-treatment 
employed  in  the  case  of  operations  for  early  acute  appendicitis.  The 
patient  sits  up  at  the  end  of  a  week,  is  out  of  bed  in  ten  days,  and  is  about 
his  business  in  from  two  to  three  weeks.  No  abdominal  belt  is  worn, 
and  no  hernia  results.  The  patient  may  indulge  in  violent  exercise 
two  months  after  the  operation  if  all  goes  well. 

Appendicitis  has  been  chosen  as  the  subject  of  this  first  chapter 
because  appendicitis  is  the  most  conspicuous  example  of  acute  abdominal 
disease.  In  the  next  chapter  we  shall  advance  upon  a  broader  field, 
and  consider  the  important  surgical  diseases  of  the  intestines  as  a  whole. 

1  The  rationale  of  this  method  has  been  admirably  explained  in  a  careful  paper 
by  M.  G.  Seelig,  Ann.  Surg.,  November,  1904,  p.  710;  and  by  H.  Lilienthal  in  Med. 
News,  November  28,  1903.  Seelig's  paper  is  so  conclusive,  and  the  large  series  of 
cases  thus  treated  is  so  successful,  that  I  unhesitatingly  recommend  this  simplest  of 
all  methods. 


CHAPTER   II 

THE  SMALL  INTESTINE  AND  COLON 

One  of  the  most  remarkable  chapters  in  the  history  of  medicine  is 
that  which  tells  of  the  development  of  our  knowledge  of  diseases  and 
injuries  of  the  intestines.  We  are  wont  to  think  that  the  days  of  ancient 
surgery,  which  ended  with  Lister's  explanation  of  the  causes  of  wound 
infection,  were  hopeless  da)^s  for  intra-abdominal  surgery,  and  espe- 
cially for  intestinal  surgery.  From  our  viewpoint  they  were  hopeless 
daj'S  so  far  as  regards  intelligent  understanding  of  conditions  and  proper 
technic,  but  the  old  surgeons  did  not  think  them  hopeless.  The  old 
surgeons  often  dealt  boldly  with  intestines  accidentally  wounded, 
though  they  themselves  rarely  opened  the  belly  to  search  for  inward 
troubles.  The  draining  and  stitching  up  of  intestinal  wounds  was  not 
uncommon,  and  ancient  literature  is  full  of  the  discussion  of  such 
matters  of  technic.  Here  are  two  illuminating  notes:  In  1826  Denans* 
introduced  silver  rings  into  the  lumen  of  the  severed  intestine,  and 
clamped  them  together  with  springs,  in  a  fashion  suggesting  the  Murphy 
button,  while  Lembert,  in  the  same  year,  described  the  extramucosa 
stitch,  which  still  goes  by  his  name.^  Lembert's  and  Denans'  principles 
survive,  and  though  we  have  improved  on  their  measures  during  the 
past  thirty  years,  it  is  interesting  and  humbling  to  reflect  upon  what 
they  might  have  done  had  Lister  lived  before  them. 

We  must  recognize  the  impossibility  of  distinguishing  always  disease 
of  the  intestines  from  associated  disease  of  other  organs,  as  well  as  from 
other  accompanying  and  complicating  diseases  of  the  intestines  them- 
selves. We  see  ptosis  of  the  bowels  combined  with  volvulus;  hernia, 
with  appendicitis;  foreign  bodies,  with  actinomycosis;  and  peritonitis, 
with  them  all.  At  the  same  time  there  are  broader  associations — calculi 
may  perforate  from  the  gall-bladder  into  the  colon;  appendicitis  may 
be  the  remote  cause  of  perigastric  adhesions  and  distortions  of  the 
stomach,  while  malignant  disease  of  any  part  may  create  its  first  incon- 
venience through  metastases  in  a  distant  organ. 

In  recent  years  writers  have  been  insisting  upon  the  association,  with 
each  other,  of  various  lesions  in  the  upper  portion  of  the  abdomen ;  but 
such  associations  are  not  limited  to  the  region  above  the  umbilicus. 
All  the  abdominal  organs,  and  organs  beyond  the  abdomen  even,  fre- 
quently are  closely  and  curiously  associated  in  disease  processes;  for 
example,  we  sometimes  see  affections  of  the  abdomen  reflected  in 
affections  of  the  chest. 

^  Recueil  de  la  Societo  Royale  de  Medecine  de  Marseilles,  1S26,  I'an  No.  1. 
-  In  South's  edition  of  Chelius'  Surgerj',  vol.  i,  p.  465;  see  an  interesting  account 
of  Shipton's  success  in  repairing  wounds  in  the  intestines  of  dogs  in  1702. 

42 


THE   SMALL   INTESTINE   AND    COLON  43 

It  is  not  proper,  therefore,  for  the  practitioner  to  study  lesions  as 
isolated  entities — the  method  commonly  employed.  He  must  approach 
his  patient  with  unbiased  mind,  and  with  a  generous  understanding  of 
the  delusion  as  well  as  of  the  significance  of  local  symptoms — an  under- 
standing favored  and  informed  by  experience  of  the  operating-room 
and  the  postmortem  table.  Regarding  misleading  or  obscure  symp- 
toms, as  I  have  said  in  another  writing,^  the  patient  who  complains  of 
morning  headache,  of  occasional  eructations,  of  some  palpitation,  and  of 
constipation  may  be  the  victim  of  gastric  cicatrices  and  beginning 
pyloric  stenosis.  The  man  who  tells  you  that  he  is  troubled  with 
distress  several  hours  after  taking  food  and  with  occasional  stomach- 
ache may  be  suffering  from  gastrectasis  or  gall-stones.  The  child  with  a 
poor  appetite,  pallor,  lassitude,  and  constipation  alternating  with  diar- 
rhea may  have  a  chronic  appendicitis.  The  rather  frail,  neurasthenic 
young  girl,  or  the  tired  mother  of  many  children,  the  sufferer  from 
dysmenorrhea,  or  the  elderly  widow  with  heartburn,  may  be  affected 
with  displacements  of  the  stomach,  the  kidneys,  or  the  uterus. 

With  some  appreciation,  then,  of  the  complicated  mechanism  with 
which  we  deal  in  approaching  all  disease,  and  particularly  abdominal 
disease,  let  us  study  in  detail  the  lesions  of  the  intestines  in  particular. 

Regarding  the  anatomy  of  the  bowels,  we  make  one  or  two  notes  of 
importance:  The  duodenum  is  but  partly  covered  by  peritoneum;  the 
jejunum  and  ileum  are  covered  completely;  and  a  portion  only  of  the 
large  intestine  is  covered  completely — the  sigmoid,  the  transverse  colon, 
and  sometimes  the  cecum.  Portions  of  bowel  but  partly  covered  are 
bound  down  and  fixed;  portions  completely  covered  by  peritoneum 
swing  at  anchor,  as  it  were;  they  are  not  grounded. 

The  position  of  the  cecum  varies  considerably :  it  may  be  high  or  low ; 
it  may  or  may  not  be  covered  with  peritoneum,  and  it  may  have  a  short 
mesentery.  The  position  of  the  splenic  flexure  of  the  colon  must  not 
be  forgotten.  It  is  higher  than  the  hepatic  flexure,  and  has  so  sharp  an 
angle  that  often  it  seems  kinked  almost,  and  as  though  contents  would 
pass  with  difficulty.  The  transverse  colon  swings  loosely  below  the 
stomach,  and  rises  and  falls  with  the  movements  of  that  organ. 

In  operating  through  a  small  parietal  opening  upon  the  intestines, 
when  a  short  loop  of  bowel  is  in  view,  one  is  constantly  faced  by  the 
important  question,  With  what  portion  of  the  gut  are  we  dealing, 
and  what  is  the  direction  of  flow  of  its  contents?  Monks  has  con- 
tributed some  valuable  information  on  these  points.^  There  is  no  normal 
length  for  the  small  intestine  in  the  adult.  It  is  from  15  to  30  feet  long. 
The  upper  6  feet  of  intestine  lie  deeply  in  the  left  hypochondrium ;  the 
middle  portions  usually  occupy  the  center  of  the  abdomen,  while  the 
lower  portions  generally  are  in  the  pelvis  or  in  the  right  iliac  fossa. 
The  upper  part  of  the  gut  is  thicker  than  any  other  part,  and  normally 
is  bright  pink  or  red,  the  color  gradually  fading  as  we  go  down,  and  the 
vascularity  becoming  less  marked.     In  the  upper  portion  the  valvulce 

1  Surgical  Aspects  of  Digestive  Disorders,  1905,  p.  xi. 

2  George  H.  Monks,  Intestinal  Localization,  Ann.  Surg.,  October,  1903. 


44 


THE   ABDOMEN 


conniventes  arc  large  and  numerous,  and  can  be  felt  always,  or  can  be 
seen  as  i)inkish  or  whitish  rings.  The}-  diminish  gradual!}-  in  number, 
but  especially  in  size  as  we  pass  downward,  until  about  the  middle 
portion,  beyond  which  they  can  seldom  be  seen.  The  mesenteric  vessels, 
opposite  the  upper  portion  of  the  bowel,  below  the  duodenum,  are  dis- 


Intestinal  localization  (Monks). 


tinctly  larger  than  elsewhere  in  the  mesentery ;  gradually  they  diminish 
as  we  pass  downward  until  the  lower  third  is  reached,  after  which  they 
retain  the  same  size.  Most  interesting  are  the  loops  of  the  mesenteric 
vessels;  opposite  the  upper  portion  there  are  primarj^  loops  onh-,  with 
an   occasional   secondary  loop.     As  a  rule,   secondary  loops  become 


Fig.  15. — Intestinal  localization  (Monks). 

prominent  at  about  the  fourth  foot  from  the  duodenum.  Going  down 
further,  secondary  loops,  and  possibly  tertiary  loops,  become  more 
numerous  and  the  primary  loops  smaller,  the  loops  all  the  time  approach- 
ing nearer  and  nearer  to  the  gut.  In  the  lower  part  of  the  mesentery 
the  loops  lose  their  characteristic  appearance  and  are  represented  b}-  a 


THI<]    SMALL    INTESTINE    AND    COLON 


45 


complicated  network.  The  vasa  recta  are  larger  and  better  defined  in 
the  upper  than  in  the  lower  portion  of  the  bowel.  The  thickness  of  the 
mesentery  varies  with  different  subjects  according  to  the  deposition  of 
fat;  but,  as  a  rule,  it  is  thinnest  in  the  upper  portion  of  the  track,  and 
becomes  thicker  as  we  descend.     In  the  upper  portion  there  may  be 


Fig.  16. — Intestinal  localization  (Monks). 


found  small,  translucent  spots  between  the  vasa  recta.  Monks  calls 
these  "lunettes,"  and  finds  that  gradually  they  grow  smaller,  become 
streaked  with  fat,  and  disappear  at  about  the  eighth  foot  from  the  duode- 
num. To  determine  the  direction  of  the  fecal  stream,  observation  of 
peristalsis  is  unreliable,  because  retroperistalsis  may  be  present;  but 


Fig.  17. — Intestinal  localization  (Monks). 

by  passing  the  fingers  down  the  side  of  the  mesentery  and  its  attach- 
ment, and  by  correcting  any  twist  that  may  be  present,  then  with  a 
finger  on  either  side  the  direction  of  the  bowel  may  be  observed.  These 
studies  of  Monks'  form  one  of  the  most  valuable  of  such  contributions  to 
the  surgery  of  the  intestines. 


46  THE   ABDOMEN 

In  Studying  intestinal  surgery  bear  in  mind  that  there  are  three  im- 
portant divisions  of  the  subject:  (a)  The  surgery  of  injuries;  (b)  of 
inflammations;  (c)  of  new-growths;  while  at  the  same  time  one  must 


II  (Monks). 


remember  constantly  that  lesions  of  the  intestines  often  are  secondary 
and  complicate  far-reaching  constitutional  disturbances.     In  consider- 


Fig.  19. — Intestinal  localization  (Monks). 

ing  these  three  types  of  disease,  remember  that  they  all  cause  death  in 
much  the  same  way — through  interference  with  metabolism,  and  in  the 
end  through  peritonitis  and  toxemia. 

SYMPTOMS 

The  examination  for  intestinal  lesions  is  a  difficult  matter  frequently, 
because  the  intestines  are  not  always  accessible  by  the  methods  employed 
in  the  examination  of  the  more  fixed  abdominal  organs.  The  patient's 
symptoms  are  an  important  guide:  Pain  suggests  the  location  of  trouble, 
but  pain  may  be  reflex  or  referred.  The  character  of  the  discharge 
from  the  bowels  is  of  value— frequent,  loose,  watery,  bloody,  lumpy, 
sHmy   movements  must   be   investigated,   while  the   microscope   and 


INTESTINAL   OBSTRUCTION  47 

chemical  tests  may  throw  further  light  on  the  problem.  Constipation 
or  complete  obstipation  suggests  an  obstruction  somewhere;  but  we 
know  that  such  conditions  may  mean  merely  the  derangement  of  organs 
outside  of  and  involving  the  intestines. 

In  studying  the  signs,  inspection  is  of  value  often.  In  a  distended 
abdomen  waves  of  peristalsis  or  retroperistalsis  may  be  seen,  and  swellings 
or  tumors  occasionally  may  show  themselves.  Inspection  of  the  rectum 
is  sometimes  useful  when  we  are  dealing  with  intestinal  lesions,  for  ob- 
structions and  sources  of  hemorrhage  may  be  discovered  there  low 
down,  while  it  is  well,  at  the  same  time,  to  distend  the  sigmoid  and  colon 
with  air  or  water,  and  then  to  determine  their  exact  position  when 
inflated,  as  well  as  their  topographic  relations  to  suspected  disease. 
Palpation  is  the  most  important  of  our  resources.  Palpation  elicits 
tenderness,  detects  resistance,  and  discovers  tumors,  masses,  or  fluc- 
tuating areas.  Percussion  discloses  tympany,  indicating  a  distended 
bowel;  dulness  or  flatness  shows  impaction,  obstruction,  collections  of 
fluid,  or  tumors.  With  a  change  of  position  of  the  patient  shifting 
fluid,  free  in  the  abdominal  cavity,  is  discovered  by  percussion.  Aus- 
cultation is  of  value  in  determining  the  presence  or  absence  of  peristalsis, 
and  in  connection  with  transmitted  heart-sounds  (see  p.  29)  it  may 
indicate  a  bowel  paralyzed  and  distended  with  gas. 

INTESTINAL  OBSTRUCTION 

The  first  and  most  conspicuous  intestinal  lesion  with  which  the 
surgeon  has  to  deal  is  obstruction  of  the  intestines.  This  may  be  com- 
plete or  partial.  It  may  be  acute  or  chronic,  and  it  may  be  due  to  a 
variety  of  causes,  many  of  which  we  shall  consider  later  in  detail, 
under  their  appropriate  headings,  such  as  volvulus,  cancer,  etc.  Writers 
discuss  sundry  degrees  of  obstruction:  stenosis,  or  narrowing;  occlusion, 
or  complete  closure;  stricture,  due  to  disease  of  the  wall  of  the  intestine; 
constriction,  due  to  pressure  from  without;  strangulation,  in  which  a 
strong  irritation  of  the  nerves  in  the  intestinal  wall  occurs,  and  at  the 
same  time  the  circulation  in  the  intestinal  wall  and  mesentery  is  so 
affected  that  severe  venous  hyperemia,  ending  in  gangrene  many 
times,  ensues.  For  our  purpose  it  is  not  necessary  now  to  consider 
elaborately  all  these  forms,  for  we  shall  deal  with  them  more  or  less  in 
the  discussion  of  special  lesions. 

Generally,  and  in  a  broad  sense,  subject  to  certain  exceptions, 
intestinal  obstructions  are  associated  with  acute  peritoneal  inflamma- 
tions, on  the  one  hand,  or  are  free  from  immediate  peritoneal  involve- 
ment, on  the  other  hand.  And  be  it  observed  that  the  peritoneal  in- 
volvements commonly  are  due  to  acute  obstructions,  while  non-involve- 
ment of  the  peritoneum  usually  indicates  chronic  obstruction.  A  con- 
spicuous example  of  the  first  is  the  acute  intestinal  obstruction  seen  in 
strangulated  hernia,  causing  "stoppage,"  with  violent  symptoms. 
An  example  of  the  second  is  seen  in  the  case  of  cancer,  slowly  encroach- 
ing upon  the  lumen  of  the  cecum,  and  shutting  off  gradually  the  fecal 
stream. 


48  the  abdomen' 

Acute  Intestinal  Obstruction 

Ileus  is  an  ancient  term  ^vhi(■h  is  now  used  to  indicate  not  a  special 
patholo<iic  condition,  but  a  group  of  SN-mptonis,  arnont^  which  four  are 
specially  present:  stoppage  of  the  fecal  stream;  abdominal  pain;  vomit- 
ing of  material  containing  bile  and  feces,  and  distention  by  gas.  This 
symptom-complex  is  serious,  because  it  indicates  an  obstruction  which 
may  fiuickly  teiininate  in  death. 

Dynamic  ileus  is  a  special  form  of  ileus,  and  is  due  to  paralysis  of 
some  portion  of  the  intestine,  and  the  effect  ma}'  be  transitory.  Such 
paralyses  arc  reflex,  and  may  be  seen  after  incarceration  of  a  testicle  in 
the  inguinal  canal,  contusion  of  the  abdomen,  and  operations  upon 
hemorrhoids.  It  appears  that  distention  of  the  intestines  with  gas 
may  produce  paralysis,  and  that  sometimes  the  action  of  bacteria  may 
produce  it,  even  though  there  be  no  evidence  of  peritonitis.  Any 
inflammation  of  the  peritoneum  may  cause  an  intestinal  paralj'sis  and 
stoppage.  Xothnagel  says  that  this  paralysis  is  reflex;  that,  at  first, 
subacute  peritonitis  may  stimulate  increased  peristalsis,  but  that,  later, 
the  absorption  of  gas  from  the  intestines  is  checked  b}'  the  peritonitis, 
and  that,  consequently,  the  gut  becomes  overdist ended,  with  a  resulting 
paralysis. 

Treatment. — The  cases  of  d}-namic  ileus  usually  are  acute,  and 
frequently  subside  spontaneously.  Treatment  consists  in  absolute 
rest,  in  abstinence  from  food,  and  in  the  cautious  use  of  moiphin  h3'po- 
dermically  to  relieve  pain.  Favorable  results  have  been  obtained  from 
the  use  of  physostigmin  to  stimulate  intestinal  action.  If  an  operation 
is  done,  its  purpose  must  be  to  remedy  the  primar}^  cause,  to  set  right 
the  organ  or  organs  whose  damage  is  giving  rise  to  the  reflex  phenomena. 
If  proper  nutrition  seem  to  be  failing  during  the  continuance  of  the 
obstruction,  nutrient  enemata  should  be  employed.  If  the  obstiiiction 
persists,  however,  and  the  patient's  symptoms  become  grave,  while 
the  true  cause  of  the  obsti-uction  is  still  obscure,  one  should  open  the 
abdomen,  and  seek,  through  draining  the  bowel,  to  relieve  the  difficulty. 
As  a  rule,  the  reason  for  dynamic  ileus  is  obvious,  and  the  surgeon  may 
content  himself  with  palliative  measures  onh'. 

Mechanical  ileus,  far  the  more  serious  form  "of  ileus,  is  commonly 
meant  when  we  speak  of  intestinal  obstruction,  and  the  varieties  and 
nature  of  such  obstructions  have  been  already  suggested.  Although  we 
use  the  terms  "acute  obstruction"  and  "chronic  obstruction,"  we  must 
bear  constantly  in  mind  that  such  terms  are  relative,  and  that  the  con- 
dition is  shifting,  for  acute  obstruction  may  be  but  a  phase  of  chronic 
obstruction,  and  chronic  obstruction  may  supervene  ujjon  a  subsiding 
acute  obstruction.  In  a  valuable  analysis  of  1000  cases  of  intestinal 
obstruction,  Gibson  enumerates  the  following  diseases:^  Hernia,  354 
cases;  intussusception,  187;  bands,  186;  volvulus,  121;  Meckel's  diver- 
ticulum, 42;  gall-stones,  40;  openings,  34;  foreign  bodies,  16;  miscel- 
laneous, 20.     These  vrere  cases  operated  upon,  and  the  death-rate  was 

1  C.  L.  Gibson,  A  Study  of  One  Thousand  Operations  for  Acute  Intestinal  Ob- 
struction and  Gangrenous  Hernia,  Ann.  Surg.,  October,  1900. 


INTESTINAL   OBSTRUCTION  49 

43.2  per  cent.,  showiiii;'  the  serious  nature  of  the  concHtion  and  suggesting 
the  frightful  niortahty  in  the  cases  left  to  nature.  The  reader  will 
notice  that  (iibson's  cases  are  practically  all  of  the  acute  type. 

^^'e  shall  consider  later  these  special  lesions,  but  let  us  note  here  the 
symptonis  common  to  them  all.  In  man}'  respects  the  s}-mptoms  are 
such  as  we  have  discussed  already  when  considering  appendicitis. 
There  are  always  pain,  nausea,  and  vomiting.  There  are  obstipation, 
abdominal  distention,  a  soft,  rising  pulse,  a  variable  temperature, 
sometimes  subnormal,  a  flushed  and  anxious  face;  late  in  the  disease  a 
bounding  pulse  frec^uentlv;  tenderness  localized  or  diffused  over  the 
abdomen,  and,  toward  the  last,  there  are  the  familiar  symptoms  of  col- 
lapse, due  to  an  intense  and  lethal  toxemia.  We  shall  have  occasion 
to  observe  these  symptoms  over  and  over  again  in  discussing  abdominal 
diseases,  and  the  student  cannot  fix  too  vividly  in  mind  the  alarming 
and  characteristic  picture. 

Pathology  of  Acute  Obstructions. — In  practically  all  these  acute 
ol^structions  the  peritoneum  quickly  becomes  involved,  the  intestines 
become  paralyzed,  and  the  affected  portion,  as  well  as  the  gut  above 
the  obstruction,  becomes  distended  with  gas.  Sharp  kinks  throughout 
the  distended  coils  occur,  frequentty  limiting  their  contents  and  checking 
both  upflow  and  downflow  of  contained  material.  In  acute  circum- 
scribed peritonitis  the  paratysis  and  dilatation  do  not  reach  their  maxi- 
mum, so  that  slight  peristaltic  motions  sometimes  may  be  observed  in 
the  affected  coils.  Acute  diffuse  peritonitis,  on  the  other  hand,  results 
in  a  complete  intestinal  paralysis. 

When  a  coil  of  intestine  with  its  mesenterj'  is  sfrangvlafed,  there 
ensues  not  alone  an  obstruction,  but  an  acute  swelling  of  the  affected 
portion.  Since  the  loop  of  intestine  is  fixed  mechanically  at  a  point  of 
constriction,  it  cannot  move,  and  all  peristaltic  motion  is  stopped  by  the 
alterations  in  the  circulation  and  innervation.  There  is  a  discharge  of 
serous  fluid  into  the  peritoneal  cavity  from  the  strangulated  intestine,  and 
in  the  course  of  twelve  hours  this  may  be  so  considerable  as  to  be  deter- 
mined by  percussion.  The  bowel  below  the  strangiuation  becomes 
empty  and  contracted.  Above  the  strangulation  it  is  distended.  It 
is  a  noteworthy  fact,  howe^-er,  that  the  more  complete  the  strangula- 
tion and  the  greater  the  shock,  so  much  the  more  slowly  does  the  bowel 
distend.  In  such  extreme  cases  death  frequenth'  results  so  soon  that 
great  distention  of  the  afferent  portion  of  the  bowel  may  not  occur. 

Conversely,  if  the  strangulation  be  incomplete  and  perhaps  a  small 
loop  only  be  affected,  the  afferent  loops  of  intestine  may  become  enor- 
mously distended,  because  the  process  of  the  disease  is  slow  and  death 
is  not  imminent.  Se\'eral  days  maj'  elapse.  It  is  always  a  suspicious 
symptom  if  one  can  feel  the  outlines  of  individual  portions  of  the 
intestine,  indicating  localized  and  extreme  distention.  Of  course,  if 
peritonitis  supervene,  there  will  result  intestinal  parah'sis  with  checking 
of  peristalsis  and  disappearance  of  the  contour  of  single  dilated  coils, 
but  as  long  as  peritonitis  is  absent,  peristalsis  continues  even  in  the 
distended  intestine,  though  such  peristalsis  is  of  varj'ing  intensity. 
4 


50  THE    Ain)OMEN 

From  such  observations  tlu^  reader  will  see  that  a  shai'p  distinction 
must  be  made  between  obstruction  associated  with  strangulation  and 
obstruction  not  so  associated.  Obstruction  from  strangulation  is 
immediately  grave.  There  is  no  anastomosis  between  the  terminal 
mesenteric  vessels  supplying  the  intestine,  so  that  occlusion  of  any  of 
the  mesenteric  arteries  results  promptly  in  necrosis  of  the  corresponding 
gut.  Therefore,  when  pronounced  s}niptoms  are  present,  associated 
with  obstruction,  we  fear  strangulation,  ^^'hen  the  s}-niptoms  are  of  a 
milder  grade,  we  may  conclude  an  obstruction  without  sti'angulation, 
and  take  our  measures  accortlingly. 

Diagnosis  of  Acute  Intestinal  Obstruction. — A  suggestion  of  the 
general  condition  of  acute  obstruction  has  already  been  given  in  the 
discussion  of  symptoms.  One  sees  at  a  glance,  from  the  Hippocratic 
face,  the  expression  of  distress,  the  shortened  respiration,  the  dorsal 
decubitus,  the  flexed  thighs,  the  tender,  distended  abdomen,  the  story 
of  constipation,  pain,  and  vomiting,  and  the  rapid,  compressible  pulse, 
that  a  serious  intra-abdominal  disease,  is  present.  Sometimes  pal- 
pation will  reveal  the  seat  of  mischief;  often  the  distention  masks  the 
lesion.  The  ]30ssible  absence  of  tympany,  combined  with  the  other 
signs,  may  suggest  an  obstruction  high  in  the  small  intestine.  In  this 
case  the  vomiting  is  not  stercoraceous.  Obstructions  lower  down, 
especially  in  the  colon,  give  opportunity  for  more  and  more  pronounced 
distention.  Examination  of  the  rectum  may  disclose  the  cause  of  the 
obstruction,  or  injection  of  the  colon  with  air  or  water  may  demon- 
strate the  seat  of  trouble.  The  adult  colon,  normally,  should  contain 
6  quarts  of  fluid;  if  one  can  introduce  less  than  4  quarts,  there  is  prob- 
ably obstruction  of  the  large  intestine.  The  age  of  the  patient  may 
have  an  important  bearing  on  the  diagnosis. 

The  history  of  hernia,  or  the  discovery  of  a  hernia  present,  will  settle 
the  diagnosis.  The  fact  of  internal  concealed  hernia  cannot  definitely 
be  ascertained.  Obstruction  in  a  young  child,  especially  if  there  be  a 
recent  history  of  colicky  pains  and  bloody,  mucous  stools,  with  the  occa- 
sional presence  of  a  rounded  or  sausage-shaped  tumor,  suggests  intus-. 
susception.  The  history  of  a  previous  abdominal  section  may  indicate 
strangulation  by  a  band,  by  adhesions,  or  the  possible  presence  of  a 
lost  sponge  or  instrument.  The  onset  of  sudden  pain,  with  collapse, 
tumor,  and  bloody  stools,  may  indicate  volvulus.  An  obstruction  due 
to  Meckel's  cHverticulum  is  almost  impossible  of  diagnosis,  so  closely 
are  its  symptoms  simulated  by  an  acute  appendicitis.  Gall-stones  may 
obstruct.  In  such  a  case  one  expects  to  find  a  histor}^  of  disease  of  the 
bile-passages,  and  probably  of  a  previous  passage  of  gall-stones.  Th^ 
presence  of  other  foreign  bodies  frequently  may  be  assumed  from  the 
history. 

In  spite  of  these  apparently  definite  suggestions,  it  is  not  by  any 
means  possible  to  make  a  positive  diagnosis  in  all  cases  of  acute  intes- 
tinal obstruction.  In  a  large  hospital  experience,  embracing  dozens 
of  these  cases  annually,  given  the  above  symptoms,  one  sees  made 
commonly  the  diagnosis  of  appendicitis,   intussusception,   peritonitis 


INTESTINAL   OBSTRUCTION  51 

from  sundry  visceral  perforations,  and  strangulated  hernia.  Then  one 
operates  for  appendicitis,  perhaps,  but  finds  thrombosis  of  the  mesenteric 
vessels  or  a  Meckel's  diverticulum.  So  the  most  experienced  surgeon 
may  make  mistakes.  Instead  of  the  suspected  diverticulum,  there  may 
be  a  volvulus,  an  internal  strangulated  hernia,  or  an  obstructing  band 
from  an  old  operation.  Moreover,  there  are  the  occasional  cases  of 
kinks  and  obstructions  due  to  ancient  and  extensive  peritonitis  of  unex- 
plained origin.  A  small  ovarian  tumor  with  twisted  pedicle  may  cause 
acute  symptoms  simulating  closely  the  symptoms  of  intestinal  obstruc- 
tion. 

Writers  will  tell  you  that  a  differentiation  may  be  made  between 
obstructions  with  strangulation  and  obstructions  without  strangulation, 
but  clinical  experience  does  not  bear  out  this  assertion.  Classic  descrip- 
tions appear  clean-cut  and  final ;  the  bedside  visit  fails  to  confirm  classic 
descriptions.  There  are,  however,  four  rules  for  the  diagnosis  of  obstruc- 
tion without  strangulation,  by  the  appHcation  of  which  we  are  some- 
times enabled  to  rule  out  strangulation.  In  simple  obstruction  there 
are:  (1)  Less  intense  and  continuous  initial  pain;  (2)  no  symptoms  of 
collapse;  (3)  clearly  marked  dilated  loops  of  intestine  to  be  made  out, 
showing  more  or  less  peristaltic  action ;  (4)  the  frequent  history  of  inde- 
finite abdominal  disturbance,  especially  of  intestinal  colic,  and  of  intes- 
tinal colic  with  constipation,  possibly  alternating  with  diarrhea.  By  the 
application  of  these  four  rules  frequently  we  may  eHminate  not  only 
strangulation,  but  peritonitis  also. 

Treatment  of  Acute  Obstruction. — When  brought  face  to  face 
with  a  case  of  intestinal  obstruction,  the  first  question  the  surgeon  asks 
himself  is.  Shall  I  operate  or  not?  Coupled  with  this  question  and 
suggesting  the  answer  is  the  secondary  query.  Are  we  dealing  with 
strangulation  or  are  we  not?  If  one  is  fortunate  enough  to  be  able 
definitely  to  answer  the  latter  question  and  assure  one's-self  that  stran- 
gulation is  not  present,  tentative  measures  are  sometimes  justifiable. 
Hernias  and  intussusceptions  may  be  reduced;  gall-stones  and  foreign 
bodies  may  pass;  and  rest,  opium,  and  intestinal  dilatation  by  enemata 
gradually  may  solve  the  difficulty.  If  such  measures  are  attempted,  the 
surgeon  must  stand  by,  ready  to  operate  if  improvement  does  not 
follow  within  a  few  hours.  Operations  in  these  emergency  cases  are  by 
no  means  so  simple  as  when  one  deals  with  properly  prepared  patients, 
because  in  the  emergency  cases  the  patient's  stomach  and  bowels  fre- 
quently are  loaded,  and  because  the  disease  has  lowered  his  resisting 
powers.  It  is  well  to  wash  out  the  patient's  stomach  at  once.  The 
preparation  of  the  skin  should  be  made  with  the  patient  on  the  operating 
table,  and  his  strength  should  be  reenforced  by  strychnin  and  warm 
bottles.  Careful  bandaging  of  the  legs  and  arms,  or  the  use  of  Crile's 
pneumatic  suit,  are  advantageous.  The  incision  is  made  over  the  sus- 
picious region,  or  in  the  median  line,  if  the  diagnosis  is  in  doubt.  The 
conditions  found  must  be  dealt  with  as  I  shall  indicate  later,  when 
speaking  of  special  lesions. 

If  strangulation  be  present,  or  if  its  presence  be  suspected  only, 


52  THE    ABDOMEN 

immediate  operation  is  imperative.  Dela}'  of  a  few  hours  will  iinolve 
gangrene  of  the  intestine,  rapid  toxemia,  and  death.  Open  the  abdomen 
by  a  long,  free  incision.  Find  the  trouble,  and  remo\e  it  at  once.  If 
intussusception,  volvulus,  Meckel's  diverticulum,  or  hernia  is  found,  the 
deranged  mechanism  sometimes  may  be  restored  without  impairment 
of  organs;  but  if  it  appears  that  necrosis  already  is  present,  the  dead 
tissue  must  be  removed.  Ba'  leaving  it  and  attempting  drainage,  a  focus 
of  infection  will  remain  and  toxemia  will  persist. 

Often  the  surgeon  is  tempted  to  do  a  partial  operation,  which  will 
relieve  the  symptoms,  but  will  not  remove  the  cause.  Such  a  partial 
operation  is  justifiable  only  in  case  the  disease  be  limited  by  peritoneal 
adhesions  or  in  case  gangrene  be  not  found.  For  instance,  if  there  are 
extensive  bands  and  cicatrices  obstructing  the  intestine,  but  not  causing 
strangulation,  and  if  the  patient's  condition  be  such  as  to  render  danger- 
ous a  radical  operation,  in  such  case  simple  drainage  of  the  bowel  by 
enterostomy^  is  permissible.  This  drainage  gives  exit  to  the  fecal 
stream;  it  favors  a  subsidence  of  the  acute  symptoms;  it  allows  a 
reestablishment  of  normal  functions;  and,  later,  should  the  patient's 
strength  be  good,  a  secondary  opera^tion  may  be  performed  to  remove 
the  primary  cause  and  restore  normal  conditions.  Another  palliative 
operation  is  entero-anastomosis.  For  example:  should  obstruction  be 
found  high  in  the  ileum  or  jejunum,  it  is  inadvisable  to  establish  there  an 
artificial  anus  by  enterostomy,  because  the  drained-away  chyle  will 
leave  the  patient  undernourished,  and  there  will  be  established  a  forai 
of  fistula  extremely  irritating  to  the  skin  and  difficult  to  care  for.  In 
these  cases  of  high  obstruction,  therefore,  the  surgeon  should  side-track 
the  disease  by  carrying  the  fecal  stream  around  it,  through  anastomosis 
of  afferent  with  efferent  intestine. 

The  after-treatment  of  the  operative  cases  must  be  followed  carefuUy. 
The  surgeon  must  endeavor  to  support  the  patient's  strength,  but  must 
limit  himself  to  mild  measures.  Nutrient  enemata  should  be  used  for 
the  first  four  days,  especially  if  intestinal  sutures  have  been  employed. 
In  the  case  of  an  artificial  anus  having  been  made,  feeding  by  the  mouth 
may  be  instituted  on  the  second  day  and  pushed  rapidly.  Through  the 
early  days  of  convalescence  one  must  be  prepared  for  secondary  shock, 
which,  in  contradistinction  to  primar}'  shock,  may  be  met  with  alco- 
holics, atropin,  and  digitalis,  in  addition  to  strychnin. 

Gastromesenteric  ileus  is  a  special  form  of  obstruction  which  has 
recently  been  obser\ed.  We  believe  it  to  be  more  common  than  at  first 
was  thought.  Gastromesenteric  ileus  is  characterized  by  a  partial 
or  complete  obstruction  of  the  duodenum,  resulting  in  a  sudden  acute 
dilatation  of  the  stomach.  The  cause  of  the  gastric  dilatation  is  still 
somewhat  debated,  though  there  seems  to  be  little  doubt  that  the 
obstruction  of  the  duodenum  is  due  to  pressure  upon  that  viscus  by 
the  superior  mesenteric  artery  near  its  origin.  It  appeal's  that  a  long 
mesentery  supporting  a  coil  of  intestine  may  so  drag  upon  the  mesenteric 

*  Note  the  distinction  between  enterostomy,  which  establishes  fecal  fistula, 
and  artificial  anus,  which  sets  a  limit  to  the  further  progress  of  tlie  fecal  stream. 


INTESTINAL   OBSTRUCTION  53 

artt-ry  as  to  compress  beneath  that  vessel  the  underlying  duodenum. 
The  ui)right  or  supine  positions  seem  to  accentuate  the  .drag  on  the 
mesenter}^  and  the  obstruction.  Conversely,  the  knee-chest  or  the 
prone  position  even  will  relieve  the  drag  and  do  away  with  the  obstruc- 
tion. This  form  of  obstruction,  the  exact  nature  of  which  M-as  long 
unrecognized,  frequently  has  been  referred  to  as  ''acute  gastric  dilata- 
tion." The  acute  gastric  dilatation  is,  indeed,  a  fact,  but  it  is  secondary 
to  the  duodenal  obstruction,  and  must  not  be  confounded  with  the  acute 
gastric  dilatation  associated  with  the  pyloric  spasm  of  gastric  tetany. 

The  symptoms  and  signs  of  acute  gastromesenteric  ileus  already 
have  been  suggested:  pain;  collapse;  frequent  vomiting,  often  of  large 
amounts,  with  an  abundance  of  bile ;  and  the  usual  evidence  of  absolute 
obstipation,  together  with  the  striking  fact  that  the  stomach,  by  per- 
cussion, is  found  to  be  enormously  distended. 

The  treatment  of  gastromesenteric  ileus  must  be  prompt,  and  must 
be  intelligent.  Rarely,  washing  out  of  the  stomach  will  relieve  the 
condition.  Frequently  the  obstruction  disappears  when  the  patient 
is  put  in  the  knee-chest  position  or  prone  on  the  belly.  If  these  measures 
fail,  the  surgeon  may  be  forced  as  a  last  resort  to  perform  gastro- 
enterostomy— artifically  connecting  the  stomach  with  the  intestine 
below  the  obstruction. 

Occasionally,  it  happens  that  gastromesenteric  ileus  follows  an 
abdominal  operation  for  some  other  cause.  These  cases  are  par- 
ticularly distressing,  and  are  most  difficult  of  management. 

Chronic  Intestinal  Obstruction 

Chronic  intestinal  obstruction  is  a  condition  found  about  as  commonly 
as  is  acute  intestinal  obstruction,  and  the  causes  are  almost  as  various. 
We  have  noted,  moreover,  that  chronic  obstruction  may  pass  into 
acute  obstruction.  We  are  wont  to  think  of  it  as  due  to  malignant 
disease,  and  occurring  after  middle  life,  but  this  is  by  no  means  the 
case.  Most  of  the  conditions  which  cause  acute  obstruction  may 
cause  chronic  obstruction;  indeed,  almost  any  circumstance  which 
gives  rise  to  a  localized  peritonitis,  with  its  associated  adhesions  and 
bands,  may  bring  about  a  narrowing  of  the  intestinal  lumen,  in  spite 
of  which  the  patient  may  go  about  for  years.  Among  such  causes  are 
incarcerated  hernia,  chronic  intussusception,  limiting  bands,  gall-stones, 
foreign  bodies,  fecal  accumulations,  and  locomotor  ataxia.  There 
are,  however,  two  other  conditions  which  are  the  conspicuous  causes 
of  chronic  obstruction:  (1)  malignant  disease  of  the  intestine  and  (2) 
the  presence  of  tumors  outside  of  the  intestine.  Another  cause  giving 
rise  to  symptoms  which  may  simulate  malignant  disease  is  narrowing 
of  the  intestinal  tube  through  cicatricial  stenosis  and  atony  of  the 
intestine. 

Symptoms  of  chronic  obstruction  may  extend  over  months  or  even 
years.  There  is  a  gradual  failure  of  health,  or  a  condition  maintained 
below  the  normal.     Sundry  dyspeptic  disturbances  are  common,  such 


54 


THE   ABDOMEN 


as  one  may  see  associated  with  chrunic  appendicitis.  There  are  occa- 
sional attacks  of  pain,  sometimes  nausea  and  vomiting,  chronic  con- 
stipation alternating  with  diarrhea,  and  periods  of  obstipation,  relieved 
after  a  time,  but  associated  with  intestinal  disturbance.  These  attacks 
are  wont  to  occur  with  increasing  fretjuency,  and  if  unrelieved  by  treat- 
ment, end  eventually  in  slow  exhaustion  and  death,  or  in  a  complete 
and  alarming  obstruction  for  which  operation  is  imperative. 

The  treatment  of  chronic  obstruction  forms  an  intricate  and  im- 
portant chapter  in  abdominal  surgery;  briefly,  it  amounts  to  this, 
that  if  we  are  dealing  with  a  patient  giving  a  long  history  of  dyspepsia, 
occasional  pain  in  the  lower  part  of  the  abdomen,  with  nausea,  vomiting, 
and  constipation,  recurring  at  intervals  and  with  gradual  loss  of  flesh 
and  strength,  we  must  operate  to  discover  the  cause  and  remove  it  if 
possible.  Bands,  adhesions,  and  external  tumors  must  be  removed. 
Damage  to  the  intestine  itself  must  be  repaired  by  section  of  the  bowel 
and  excision  of  the  diseased  portion,  or,  if  the  patient's  condition  is 


Fi^.  20. — End-to-end  anastomosis. 

serious,  we  must  content  ourselves  with  the  palliative  operations  of 
making  an  artificial  anus  or  performing  anastomosis. 

So  much  for  a  general  consideration  of  intestinal  obstruction, 
acute  and  chronic.  Let  us  now  make  a  brief  study  of  the  special  in- 
testinal lesions  with  which  the  surgeon  is  concerned. 


INJURIES 

Injuries  to  the  intestines  commonly  are  of  three  sorts:  (1)  Tho.se 
from  sudden  blows;  (2)  those  from  crushes;  (3)  those  from  penetrating 
wounds;  and  in  all  three  types  of  injury  the  damage  to  the  intestine 
may  be  out  of  all  proportion  to  the  apparent  violence.  I  do  not  in- 
clude here  foreign  bodies  which  may  cause  trouble  within  the  bowol. 
Rarely,  the  intestines  may  be  niptured  by  increased  tension  from 
within.  Blows  and  crushes  may  injure  the  viscera  without  greatly 
contusing  the  skin.  In  such  cases  one  finds  ecchymoses  of  the  gut 
and  of  the  mesentery;  tears  of  both;  free  blood  or  blood  mixed  with 
feces  and  gas  in  the  peritoneal  cavity.     Xot  long  ago  I  was  called  to 


INJURIES  55 

attend  a  child  of  three  years,  who  was  said  to  have  been  knocked  dovv^n, 
but  not  run  over,  by  a  dray.  There  was  little  or  no  collapse,  the  child 
was  wailing,  but  not  dull  or  lethargic,  the  skin  was  moist  and  warm; 
the  temperature  was  normal;  the  pulse  was  100;  there  was  a  slight 
external  bruise,  rigidity  of  the  left  lower  portion  of  the  abdominal 
wall,  and  tenderness  across  the  abdomen  below  the  navel.  The  case 
was  obscure,  but  after  watching  it  for  a  short  time  it  was  evident  to 
me  that  some  form  of  visceral  lesion  was  present — the  evidence  was  a 
rising  pulse,  with  increasing  pallor,  restlessness,  and  some  clamminess 
of  the  skin.  I  opened  the  abdomen  hastily,  and  found  three  feet  of 
intestine  torn  loose  from  the  mesentery,  in  which  were  two  spouting 
arteries;  there  was  also  a  small  rent  in  the  intestine,  with  escape  of  its 
contents.  Such  cases  are  not  uncommon,  and  the  obscurity  of  the 
symptoms  in  this  particular  instance  suggests  the  difficulty  often  of 
accurate  diagnosis. 

In  the  case  of  penetrating  wounds  of  the  abdomen,  which  are 
usually  due  to  gunshots  or  knife-thrusts,  the  immediate  symptoms 
frequently  are  deceptive  also  and  their  severity  is  dependent  more 
or  less  upon  whether  or  not  the  intestines  be  loaded.  A  bullet  usually 
inflicts  more  than  one  wound  on  the  gut,  for  it  may  penetrate  several 
superimposed  coils.  Usually  fecal  contents  and  gas  escape  into  the 
peritoneal  cavity,  and  there  may  be  extensive  hemorrhage  from  lacera- 
tion of  the  mesentery.  A  knife-thrust  is  less  dangerous,  for  a  knife 
may  push  aside  the  bowel  it  encounters.  Penetrating  wounds  of  the 
thin  small  intestine  are  more  fatal  than  wounds  of  the  thicker  stomach 
and  colon. 

The  diagnosis  of  trauviatic  intestinal  'perforation  is  extremely  difficult. 
We  look  for  the  cardinal  signs  of  collapse — constant  pain  and  tenderness, 
clammy  skin,  rapid  and  thready  pulse,  and  a  subnormal  temperature; 
rigidity,  shifting  dulness  on  percussion,  but  with  an  increasing  tympan- 
ites. Frequently  there  is  vomiting,  at  first  bloody,  later  stercoraceous, 
and  there  may  be  bloody  stools,  but  usually  the  bowels  do  not  move. 
Often  these  signs  fail  us.  In  the  great  majority  of  cases,  however, 
if  there  has  been  a  wound  of  the  intestines,  we  may  be  certain  that 
death  wiU  ensue  unless  there  be  active  surgical  intervention. 

The  treatment  in  all  such  cases,  even  though  the  extent  of  the  damage 
be  doubtful,  is  exploration  by  opening  the  abdomen.  Combat  shock 
by  small  doses  of  morphin  and  by  bandaging  the  extremities.  Have 
the  patient  upon  a  hot-water  table  or  surrounded  by  heaters.  Open 
quickly  in  the  median  line;  wipe  out  blood  and  extra vasated  material; 
clo  not  employ  extensive  irrigation;  find  the  source  of  hemorrhage  and 
check  it;  overhaul  the  intestines  and  repair  rents;  excise  badly  torn 
bowel  and  mesentery;  drain  with  gauze  strands  or  a  cigaret  wick, 
carry  one  wick  at  least  to  the  bottom  of  the  pelvis,  and  sew  up  quickly 
with  through-and-through  stitches.  Place  the  patient  in  bed  in  the 
semi-upright  (Fowler's)  position;  keep  him  warm;  keep  him  quiet 
with  morphin;  and  for  thirty-six  hours  withhold  aU  food,  water,  and 
drugs  by  mouth  or  rectum.     For  the  thirst,  inject  saline  solution  under 


56  THE    A1?I)()MEN 

the  skin  of  the  breast  or  into  a  vein.  For  secondary  shock  employ 
strychnin  carefully.  In  case  there  is  evidence  of  spreading  jx-ritonitis, 
endeavor  to  condxit  it  by  slow,  continuous  saline  irrigation — the 
method  of  J.  B.  Murphy,  which  I  describe  in  detail  in  Chapter  Mil. 
If  convalescence  progresses,  feed  by  nutrient  enemata  for  five  days 
after  the  second  day;  then  water  and  nourishing  liquids,  without  milk, 
gradually  may  be  given  by  mouth.  At  the  end  of  ten  days,  if  all  goes 
well,  we  may  regard  the  convalescence  as  establishc^l,  and  ma}'  treat 
the  patient  as  in  the  convalescence  from  appendicitis. 

The  prognosis  is  grave  in  all  these  cases.  Although  surgeons  report 
brilliant  results,  the  practitioner  must  not  count  upon  a  low  death- 
rate.  Brilliant  results  may  be  ascribed  to  superior  technic  or  to  good 
luck;  but  in  the  routine  of  a  large  accident  service,  or  in  the  experience 
of  a  busy  practitioner,  injuries  to  the  intestines  always  must  be  regarded 
as  grave. 

FOREIGN   BODIES 

Foreign  bodies  may  cause  injury  to  the  intestines.  They  usually 
come  down  through  the  stomach;  sometimes  they  enter  from  outside; 
sometimes  they  enter  through  the  anus.  When  inside  the  intestine, 
they  work  damage  through  obstructing  the  canal,  setting  up  perforating 
ulcers,  or  themselves  penetrating  the  intestinal  wall,  and  we  must  note 
that  such  perforating  and  penetrating  lesions  may  heal  aftenvard,  so 
that  the  adhesions  even  are  absorbed.  A  man  may  survive  the  experi- 
ence of  having  bodies  in  the  peritoneal  cavity  work  through  into  the 
intestines.  One  writer  found  that  10  out  of  2S  pieces  of  gauze  left  by 
accident  in  the  abdominal  cavity  passed  per  anum;  while  1  of  4 
drainage-tubes,  and  3  of  17  artery  forceps,  so  left,  also  passed  per  anum. 

Foreign  bodies  introduced  into  the  rectum  do  not  work  their  way 
upward  beyond  the  ileocecal  valve.  Obstnjcting  bodies  may  form 
within  the  intestines,  such  as  enteroliths,  fecal  calculi,  or  fecal  tumors. 
The  fibers  of  plants,  the  seeds  and  fibers  of  fruit,  or  pin-worms  may 
be  matted  together  to  form  the  nucleus  of  an  obstructing  ball.  As  a 
usual  thing,  however,  any  object  which  passes  through  the  narrow 
pylorus  will  seldom  find  difficulty  in  passing  the  length  of  the  intestines, 
even  through  the  ileocecal  valve.  When  such  bodies  do  lodge,  they 
will  be  found  at  the  ileocecal  valve,  at  the  flexures  of  the  colon  and 
duodenum,  and  most  commonly  at  the  sphincter  ani. 

The  small  size  of  obstructing  bodies  is  surprising  often,  and  this  is 
true  especially  of  biliary  calculi.  Such  calculi,  larger  than  1.2  inches 
in  diameter,  rarely  pass  through  the  intestines  without  causing  trouble. 
Sharp-pointed  bodies,  such  as  open  safety-pins,  may  stick  in  the  lining 
of  the  gut. 

Symptoms  and  Diagnosis. — Often  there  is  the  history  of  a  foreign 
body  swallowed  or  otherwise  introduced.  Sometimes  foreign  bodies 
may  be  felt  through  the  abdominal  wall.  There  may  be  a  history 
of  gall-stones  passed,  or  the  fact  of  a  recent  abdominal  section  may 
suggest  the  retention  of  a  sponge  or  instrument.     The  sj-mptoms  are 


Meckel's  divekticulum  57 

those  of  intestinal  ol)stnietion:  pain  increasing,  localized  tenderness, 
nausea  and  vomiting,  constipation,  a  rise  of  temperature  and  puLse, 
freiiuently  a  rising  leukoc3-tosis;  abdominal  distention,  tympany, 
rigidity.  Sometimes  intestinal  perforation  or  penetration  by  a  sharp 
object  may  be  walled  off,  with  a  resulting  localized  abscess.  Needles 
or  splinters  of  bone  or  wood  may  penetrate  the  wall.  Recenth',  in  the 
hands  of  a  colleague,  I  saw  a  case  which  had  simulated  malignant 
disease  of  the  abdominal  wall.  Exploration  disclosed  actinomycosis 
introduced  by  means  of  a  sharp  fish-bone,  which  was  found  to  have 
worked  its  way  outward  from  within  the  intestine. 

Fecal  tumors  simulate  neoplasms  and  may  remain  side-tracked 
and  obstinately  present  while  the  fecal  stream  flows  by,  and  the  patient 
has  regular  movements  of  the  bowels.  Such  fecal  tumors  are  found 
in  the  cecum,  the  sigmoid,  and  the  flexures  of  the  colon.  They  are 
doughy,  and  pit  on  pressure.  There  is  little  evidence  that  fecal  masses 
of  this  nature  cause  ulceration  and  perforation,  as  do  fecal  calculi  and 
other  hard  bodies. 

Treatment. — Gradually,  foreign  bodies  will  pass  through  the  in- 
testines and  reach  the  anus  if  time  be  allowed.  Fecal  masses  may  be 
dislodged  by  abundant  doses  of  oil  and  by  saline  purges.  When  a  foreign 
body  is  suspected,  however,  especially  in  the  case  of  children,  the  patient 
must  be  kept  under  observation  until  the  object  is  recovered  in  the 
stools. 

If  serious  symptoms  arise,  such  as  I  have  described,  we  must  operate 
promptly.  Should  the  foreign  body  be  found  within  the  undamaged  intes- 
tine, a  simple  enterotom}^,  removal  of  the  body,  and  sewing  up  will  suffice ; 
drainage  is  needless.  Should  the  intestine  be  found  damaged,  however, 
with  involvement  of  the  peritoneum  and  underlying  structures,  the 
surgeon  must  remove  the  offending  material  and  wipe  out  and  drain 
as  though  dealing  with  an  inflamed  appendix.  The  after-treatment 
is  hke  that  following  operation  for  acute  appendicitis. 

MECKEL'S  DIVERTICULUM 

The  existence  of  this  diverticulum  has  been  recognized  for  two 
hundred  j^ears,  but  only  recently  have  we  known  it  as  a  source  of 
danger,  and  with  accumulating  experience  we  see  that  it  is  increas- 
ingly important.  About  2  per  cent,  of  mankind  carry  a  Meckel's 
diverticulum,  and  its  disease  is  thrice  as  common  in  men  as  in  women. 
In  6  per  cent,  of  all  obstruction  cases  this  diverticulum  is  said  to  be  at 
fault. ^  When  present,  it  is  a  danger  to  life  in  more  waj'S  than  is  the 
appendix.     It  is  a  menacing  and  little  appreciated  organ. 

The  diverticulum  of  Meckel  is  a  fetal  remnant  of  the  intestinal  tract, 
an  incomplete  obliteration  of  the  vitello-intestinal  duct.  Normally,  it 
disappears  long  before  birth,  but  it  may  remain  as  an  open  duct  con- 
necting the  bowel  with  the  outer  world  by  way  of  the  navel.  Part 
of  it  may  atrophy,  leaving  a  blind  pouch  out  of  the  bowel,  and  strung 
1  A.  E.  Halstead,  Ann.  Surg.,  1902,  vol.  xxxv,  p.  471. 


58 


THE    ABDOMEN 


by  its  tip  to  the  navel;  or  it  may  be  a  nicro  blind  pouch,  similar  to  the 
appendix.  Generally,  it  sj)rings  from  the  ileum,  from  15  to  30  inches 
above  the  ileocecal  valve,  but  it  ma}-  arise  from  any  part  of  the  intestine, 
and  usually  from  the  side  opposite  the  mesenteric  attachment.  When 
you  operate  for  supposed  appendicitis  and  find  the  appendix  normal, 
search  for  a  Meckel's  diverticulum.  Its  blood-  and  nerve-supply  are 
those  of  the  intestines,  as  its  musculature  is  from  the  intestines. 

Sometimes,  through  persistent  granulation  at  the  navel,  there  is 
external  evidence  of  a  chverticulum;  and,  when  ])atulous  throughout, 
it  may  form  the  sac  of  an  umbilical  hernia. 

This  brief  sketch  of  the  anatomy  shows  that  a  IMeckel's  diverticulum 
may  cause  trouble  in  two  ways — by  becoming  diseased  itself,  like  the 


Fig.  21. — Meckel's  diverticulum   (Warren  Museum,  Harvard,  Specimen  No.  7915). 


appendix,  or  by  obstructing,  entangling,  and  strangulating  the  gut  in 
some  fashion. 

Inflammation,  or  diverticulitis,  as  it  has  been  called,  has  occurred 
in  about  13  per  cent,  of  the  reported  cases  of  diseased  diverticula,^  and 
among  these  are  a  few  from  typhoid  and  tuberculous  ulcers.  Far  more 
commonly  it  acts  by  strangulating  the  bowel  as  by  a  band — 59  per  cent. ; 
while  there  are  many  cases  of  intussusception,  or  telescoping  of  the 
diverticulum  (10  per  cent.),  of  hernia  (10  per  cent.),  and  several  cases 
of  volvulus  or  twist  about  the  diverticuhim. 

It  appears  that  when  the  diverticulum  forms  a  mere  cord  from  gut 
to  navel,  strangulation    of    the  intestine  is  probabl}-  never  produced. 

1  Miles  F.  Porter,  Jour.  Amer.  Med.  Assoc,  September  23,  1905,  discusses  184 
reported  cases  in  a  valable  paper,  "Abdominal  Crises  Caused  by  Meckel's  Divertic- 
ulum." 


Meckel's  diverticulum  59 

It  is  the  free  diverticulum  secondarily  fixed  to  portions  of  the  viscera 
which  makes  trouble.  Again,  the  free  end  may  become  club-shaped 
through  ampullary  dilatation,  and  twist  and  knot  itself  about  the  in- 
testines. Sundry  other  rare  forms  of  interference  with  the  bowel  are 
described.  Unfortunately,  the  exact  condition  cannot  be  determined 
at  the  bedside;  the  results  only  are  seen,  and  these  are  nearly  always 
ascribed  to  acute  appendicitis.  The  clinical  pictures  of  the  two  are 
similar.  Meckel's  diverticulum  is  diseased  most  commonly  in  young 
men,  averaging  twenty-one  years  of  age. 

The  S5nnptoins,  then,  in  most  cases,  are  those  of  a  peritonitis,  or  of 
an  obstruction  with  or  without  strangulation,  pointing  to  a  distur- 
bance localized  below  the  navel,  and  generally  to  its  right. 

The  diagnosis  cannot  accurately  be  made,  therefore,  but  with  the 
symptoms  of  pain,  tenderness,  nausea  and  vomiting,  constipation, 
distention,  sometimes  a  tender  mass  below  the  umbilicus,  fever,  rapid 
pulse,  and  late  collapse,  indicating  profound  toxemia,  one  must  conclude 
that  there  is  present  a  serious  intestinal  derangement,  obstructive  and 
infective,  and  must  operate  for  its  relief. 

Treatment. — When  the  abdomen  is  opened  and  the  suspected 
appendix  is  found  uninvolved,  search  must  be  made  for  a  diverticulum. 
If  that  be  discovered,  the  condition  present  must  be  treated  appro- 
priately. The  diverticulum  should  be  excised,  and  the  stump  turned 
in  with  a  purse-string  or  with  Lembert  sutures;  further  than  that,  a 
localized  or  general  peritoneal  infection  must  be  treated  on  the  lines 
laid  down  in  the  chapter  on  peritonitis;  bands  must  be  removed, 
twists  and  intussusceptions  reduced,  necrotic  gTit  excised,  and  the 
abdomen  drained.  The  after-treatment  does  not  differ  from  that  for 
appendicitis.     Fowler's  position  is  a  valuable  aid  in  securing  drainage. 

When,  in  the  course  of  any  abdominal  operation,  a  diverticulum  is 
found,  it  should  be  removed. 

The  mortality  from  diseased  Meckel's  diverticulum  untreated  is 
about  60  per  cent.  In  cases  promptl}'  operated  upon  the  mortality  is 
about  10  per  cent.^ 

Diverticula  of  the  sigmoid  are  almust  always  acquired,  as  dis- 
tinguished from  Meckel's  diverticula,  which  are  congenital.  The 
acquired  diverticula  may  occur  elsewhere  than  in  the  sigmoid  flexure, 
but  they  are  extremely  rare  in  other  portions  of  the  intestinal  tract. 
Frequently,  they  lead  to  disease.  These  acquired  diverticula  may  be 
true  or  false — that  is  to  say,  there  ma}'  be  a  pouching  at  some  point  of 
all  the  coats  of  the  intestinal  wall,  or  there  may  be  a  hernia  of  the 
mucosa  through  a  rent  in  the  muscularis.  This  last  is  a  false  divertic- 
ulum, and  is  far  the  most  common.  Disease  of  these  diverticula  may 
arise  to  simulate  appendicitis.  Indeed,  at  one  time  surgeons  were  in- 
clined to  look  for  a  transposition  of  viscera  when  they  had  to  deal  with 
acute  inflammatory  processes  in  the  left  iliac  region. 

Constipation  is  regarded  as  an  important  factor  in  the  production 

1  Leon  Cahier,  L'inflammation  des  diverticules  intestineaux  ou  diverticulite, 
Revue  de  chir.,  September,  1906. 


60  THE  abdomp:n' 

of  diverticulitis.  Hardened  focal  masses  are  commonly  found  in  the 
sigmoid,  and  ma}'  lead  ultimately  to  inflammation,  which  accounts  for 
the  fact  that  sigmoid  diverticula  are  more  commonly  inflamed  than 
are  vermiform  appendices.  Most  of  the  cases  of  diverticulitis  occur 
in  persons  of  middle  age.  The  attacks  may  be  acute  or  may  be  chronic, 
and  the  clinical  course  in  either  case  closely  resembles  analogous  disease 
of  the  vermiform  appendix. 

The  treatment  is  generally  quite  like  that  employed  for  appendicitis, 
though  W.  J.  Mayo  advises  resections  of  the  gut  in  certain  cases.  His 
admirable  summary  of  the  treatment  is  as  follows:  "The  surgical 
treatment  of  diverticulitis  of  the  colon  depends  upon  the  condition 
present,  thirst,  localized  suppurative  cases  must  be  treated  by  free 
drainage.  If,  in  conjunction  with  the  infective  process,  acute  obstruc- 
tion of  the  bowels  develops,  as  in  the  cases  reported,  a  temporary'  arti- 
ficial anus  should  be  made,  and,  if  necessary-,  after  the  infection  has 
subsided,  the  involved  colon  may  be  resected.  Second,  if  a  considera- 
ble tumor  is  present  and  the  symptoms  do  not  show  a  tendency  to  dis- 
appear, it  is  better  to  make  a  primary  resection  of  the  affected  part  of 
the  bowel,  before  abscess  and  fistula  supervene  to  render  patients  pro- 
longed invalids."  This  advice  of  Mayo  seems  to  suggest  extremely 
radical  treatment;  as  a  fact,  the  larger  number  of  cases  of  diverticulitis 
recover  promptly  with  the  opening  and  draining  of  the  abscess.^ 

ENTEROPTOSIS 

Enteroptosis — displacement  or  prolapse  of  the  intestines — is  an- 
other common  condition  of  serious  importance.  It  leads  to  multiplied 
and  distressing  symptoms,  and  is  a  cause  of  .serious  chronic  ill  health. 
Some  notion  of  visceral  ptosis  has  long  been  held — Yirchow  had  words 
to  say  about  it  nearly  fifty  years  ago,  but  it  remained  for  Glenard,  in 
1885,  to  accentuate  its  importance.  He  described  especially  a  prolap.se 
of  the  small  intestine,  transver.se  colon,  stomach,  and  right  kidney. 
He  named  this  combination  ''enteroptosis,"  though  that  name  should 
apply  properly  to  descent  of  the  intestines  onh'.  The  affection  is 
sometimes  called  "Glenard's  disease."^ 

Etiology. — The  condition  is  most  common  in  women  and  may  be 
due  to  both  congenital  and  acquired  peculiarities.  Owing  to  stnictural 
development,  to  flabby  abdominal  muscles  weakened  by  severe  illness, 
to  improper  clothing,  or  to  pregnancies,  the  normal  abdominal  tension 
is  diminished;  the  transverse  colon  is  loosened,  usually  at  the  hepatic 
flexure,  and  sags  downward,  and  it  crowds  the  coils  of  the  .small  intestine 
so  that  they  in  turn  press  upon  the  pelvic  organs,  which  become  dis- 
placed in  turn.  The  stomach  follows  the  intestines,  and  the  right 
kidney  frequently  sinks  loosely  below  its  normal  position. 

1  G.  E.  Brewer,  Amer.  Jour.  Med.  Sci.,  October,  1907,  and  .Jour.  Amer.  Med. 
Assoc,  August  lo,  1908.  W.  J.  Mayo.  Surg.,  Gyn.,  and  Obstet.,  July,  1907.  Edwin 
Beer,  Amer.  .Jour.  Med.  Sci.,  July,  1904. 

-  For  a  fairly  comprehensive  account  of  abdominal  ptosis  the  reader  is  referred 
to  the  writer's  Surgical  Aspects  of  Digestive  Disorders,  1905. 


ENTEROPTOSIS 


Gl 


There  results  a  train  of  symptoms  so  complex,  obstinate,  and  puz- 
zling tliat  it  is  impossible  often  to  determine  what  organs  are  at  fault, 
and  frequently  symptoms  are  assigned  to  derangements  of  the  stomach, 
kidney,  or  uterus,  when  the  true  condition  is  one  of  prolapse  of  the  in- 
testines and  stomach,  which  must  be  dealt  with  together.  Gastric 
dilatatioii  frequently  is  associated  with  gastric  ptosis.  As  a  result  of 
these  combined  ptoses,  we  see  a  condition  often  assigned  to  neuras- 
thenia— the  symptom-complex  insomnia,  irritability,  headache,  malaise, 
anorexia,  abdominal  pain,  especially  after  meals,  obstinate  constipa- 


Fig.  22. — Diagram  showing  normal  position  of  liver,  stomach,  colon,  and  kidneys. 
Kidneys  and  ureters  indicated  by  heavy  black  line. 


tion,  ''dyspepsia."  The  patient  is  long  waisted,  emaciated,  with  a  dry 
skin  and  flabby,  pendulous  abdomen.  Rectal  examination  may  dis- 
cover displaced  pelvic  organs,  while  the  rectum,  normally  ballooned,  is 
collapsed  and  admits  the  finger  with  some  difficulty.  These  patients 
are  in  a  condition  of  continual  wretchedness;  they  are  subject  to 
occasional  crises  of  pain  and  to  a  constant  sensation  of  "falling  to 
pieces."  Of  course,  there  are  lesser  degrees  of  the  malady,  especially 
in  young  women  who  have  not  borne  children,  in  whom  neuralgias  and 
obscure  symptoms  of  discomfort  alone  suggest  that  the  cause  may  be 
intestinal  ptosis. 


62 


THE    ABDOMEN 


Treatment. — Wc  shall  discuss  later  the  extensive  and  grave  ptoses 
of  special  abdominal  organs,  and  the  operations  \v'hich  have  been  rec- 
ommended for  their  relief.  As  to  the  treatment  of  intestinal  ptosis — 
that  is  rarely  oi)erativo.  Kest, — especially  in  the  open  air, — a  care- 
fully regulated  diet,  gentle,  regular  exercises  directed  mainly  to  strength- 
ening the  abdominal  nmscles,  mild  laxatives,  high  cold  enemata,  the 
wet-pack,  and  massage  usually  will  improve  or  rectify  the  evil.  Espe- 
cially valuable  is  the  wearing  of  well-fitting  straight-front  corsets,  loose 
at  the  top  and  tight  at  the  ])ottom,  so  as  to  raise  the  viscera.     We  hear 


Fig.  23. — Diagram  showing  ptosis  of  liver,  stomach,  colon,  and  right  kidney.   Kidneys 
and  ureters  indicated  by  heavy  lines. 


talk  of  carefully  applied  abdominal  belts.  Abdominal  belts  are  hard 
to  fit,  but  a  proper  bandage  is  extremely  useful  and  gives  the  patient 
immediate  relief.  To  apply  it,  the  patient  should  lie  down  with  the 
pelvis  raised  on  a  pillow,  and  a  roller  bandage.  6  inches  wide,  should  be 
carefully  put  on,  caught  first  about  the  thigh  and  then  carried  smoothly 
and  firmly  about  the  abdomen  from  pubes  to  xiphoid— tighter  at  the 
bottom  than  at  the  top. 

Such  should  be  a  routine  treatment  for  intestinal  ptosis  of  whatever 
severity.     Sometimes  a  sagging  and  collapsed  transverse  colon  must 


COLITIS  63 

be  stitched  up  to  the  abdominal  wall;  sometimes  a  sigmoid,  twisted 
and  dilated  and  causing  chronic  obstruction,  must  be  reduced;  but, 
as  a  rule,  the  simpler,  non-operative  measures  will  give  relief. 

COLITIS 

Certain  inflammations  originating  in  the  interior  of  the  bowel 
may  become  subject  to  surgical  treatment.  Among  these  affections 
are  diffuse  or  localized  catarrhs  and  their  sequelae,  sometimes  run- 
ning a  limited  course,  sometimes  becoming  chronic.  Owing  to  the 
nature  of  the  contents  of  the  small  intestine  and  the  presence  of 
active  chemical  agents  there,  it  is  rarely  permissible  to  operate  for  in- 
flammation within  this  portion  of  the  intestinal  tract.  We  may  treat 
the  colon,  however,  through  an  artificial  fistula.  In  certain  cases  of 
protracted  colitis  such  treatment  is  valuable. 

Mucous  colitis,  known  by  various  other  names,  such  as  mucous 
colic,  membranous  enteritis,  and  tubular  diarrhea,  is  an  obstinate  and 
peculiar  affection.  It  is  confined  to  the  colon,  and  is  characterized 
by  the  production  of  a  tenacious  mucus,  which  may  be  passed  in  small 
or  large  quantities,  in  lumps,  in  strings,  or  in  the  appearance  of  a  mem- 
brane. It  is  commonly  seen  in  neurasthenic  women,  more  rarely  in 
men.  Osier  describes  the  disease  as  a  secretion  neurosis  of  the  colon. 
There  are  two  types:  (1)  The  neurotic  and  hysteric,  in  men  and  women; 
(2)  cases  clue  to  local,  uterine,  tubal,  and  ovarian  troubles. 

Symptoms. — The  disease  is  known  and  characterized  by  paroxysms 
of  abdominal  pain,  with  tenderness,  occasional  tenesmus,  and  such 
passages  of  mucus  as  I  have  described.  Frequently  one  sees  it  as- 
sociated with  visceral  ptosis.  The  abdominal  walls  are  flabby  and 
relaxed,  while  the  stomach,  right  kidney,  and  especially  the  transverse 
colon  are  fallen  out  of  place.  Not  infrequently,  after  a  long  con- 
tinuance of  the  disease,  the  appendix  becomes  affected,  so  that  the 
wretched  patient  may  have  a  chronic  appendicitis  or  even  an  acute 
appendicitis,  superimposed  upon  the  already  existing  conditions.  It 
has  been  thought  that  mucous  colitis  is  at  times  a  sequel  of  chronic 
appendicitis,  but  such  a  supposition  reverses  cause  and  effect.  Some- 
times the  patients  have  bloody  stools  and  sometimes  they  have  other 
associated  distressing  dyspeptic  symptoms.  These  persons  are  easily 
affected  by  all  sorts  of  fanciful  or  actual  worriments,  which  may  give 
rise  to  acute  crises  of  pain.  They  may  be  victims  of  morphin  and  other 
drug  habits  also. 

The  diagnosis  is  not  difficult,  for  the  discharges  are  characteristic, 
but  the  associated  lesions,  especially  the  ptosis,  must  be  carefull}'  in- 
vestigated. 

Treatment  is  unsatisfactory.  Best  of  all  perhaps  is  a  long  period 
of  proper  sanatorium  life,  if  that  can  be  secured;  and,  in  addition  to 
improved  hygiene  and  relief  from  anxiety,  there  should  be  prescribed 
carefully  applied  abdominal  bandages  to  support  the  prolapsed  viscera. 
Copious  daily  saline  irrigations  may  well  be  employed,  sometimes  carry- 
ing bismuth,  sometimes  nitrate  of  silver  or  other  drugs. 


64  THE    ABDOMEN 

In  a  good  many  cases,  however,  cures  are  effected  by  the  medium 
of  irrigation,  through  colostomy,  and,  if  other  methods  have  failed  and 
the  jjatient  is  not  too  much  exhausted  to  bear  the  slight  shock  of  this 
operation,  it  should  be  cmi)loycHl  moi-e  fn^iucntly  than  in  the  past.  The 
abdomen  is  opened  through  a  low  Mcliuiney  incision  on  the  right,  the 
colon  is  drawn  out  of  the  wound,  and  a  soft  catheter  is  inserted  into  it, 
as  in  the  case  of  a  Witzel's  gastrostomy.  (See  p.  152.)  The  colon 
should  be  caught  up  by  four  stitches  to  the  parietal  peritoneum,  and 
then  allowed  to  sink  back  into  the  abdominal  cavity,  which  should  be 
closed  about  the  protruding  catheter.  Through  the  catheter  iriigation 
may  be  introduced  daily  and  in  copious  quantities.  At  the  end  of  a 
week  the  catheter  may  be  withdrawn,  but  should  be  reinserted  daily 
for  the  regular  washings.  When  it  is  not  in  place,  the  valve-like  open- 
ing in  the  wall  of  the  cecum  closes,  and  prevents  the  escape  of  in- 
testinal contents.  Weir  has  suggested  utilizing  the  appendix  as  a 
passage  for  irrigation,  rather  than  opening  the  cecum,  and  his  method 
has  met  with  favor.  ^ 

I  have  employed  Weir's  appendicostomy  with  the  highest  satis- 
faction. 

TYPHOID    PERFORATION 

Far  more  important  than  simple  injiamvKitions  of  the  mucosa  are 
-perforations  of  the  gut  which  originate  in  such  inflammations  as  we 
have  been  discussing;  and  the  most  important  of  these  perforations 
is  that  of  typhoid.  In  recent  years  valuable  contributions  to  the 
literature  of  this  subject  have  been  furnished  us  by  Gushing,  Briggs, 
Harte,  and  Ashhurst.- 

When  it  occurs,  this  formidable  complication  of  typhoid  fever  is 
seen  commonly  in  the  third  week  of  the  disease.  So  frequent  is  it  that 
its  recognition  and  treatment  must  be  regarded  as  important  items 
in  the  study  of  typhoid — a  disease  with  which  surgeons  should  be 
conversant.  Probably  more  than  30  per  cent,  of  the  deaths  from 
typhoid  are  due  to  perforation,  so  that  in  the  United  States  alone,  in 
the  year  1896,  16,660  deaths  were  due  to  this  cause;  and  it  seems  fair 
to  state  that  at  least  5000  of  these  deaths  might  have  been  prevented 
by  an  early  recognition  of  the  perforations,  followed  by  proper  opera- 
tions. 

About  75  per  cent,  of  the  perforations  occur  in  the  lower  portion  of 
the  ileum,  mostly  within  12  inches  of  the  ileocecal  valve.  Rarely  the 
colon  itself  is  perforated;  still  more  rarely,  the  appendix,  a  Meckel's 
diverticulum,  or  the  rectum  even.  There  are  exceptions  to  these 
statements.  Last  year,  in  the  Massachusetts  General  Hospital,  I 
operated  upon  a  case  in  which  5  perforations  were  discovered  in 
the  jejunum.     In  view  of  such  facts  and  of  the  frequent  obscurity  of 

1  The  term  appendicostomy  is  used.  Wiien  the  iiealinf!;  of  the  diseased  colon 
is  complete,  the  appendix  is  removed. 

2  Harvey  f'ushing,  Johns  Hopkins  Hosp.  Bull.,  November,  1898:  V.  E.  Brigps, 
Amer.  Jour.  Med.  Sci.,  May,  1903;  Harte  and  Ashhurst,  Ann.  Surg.,  January,  1904. 
R.  H.  Harte,  Jour.  Amer.  Med.  Assoc,  October  28,  1905. 


TYl'HOID    rEUFOKATION  65 

diagnosis,  it  would  sccni  proper,  as  Osier  has  recommended,  that  all 
cases  of  typhoid  fever  should  be  subject  to  regular  surgical  observation 
when  possible. 

Etiology. — Though  the  majority  of  cases  occur  in  the  third  week, 
perforations  have  been  known  as  early  as  the  fifth  day  after  the  disease 
had  declared  itself;  indeed,  perforation  may  be  the  first  evidence  of 
typhoid.  At  the  other  extreme,  there  have  been  cases  of  perforation 
after  convalescence  was  thought  to  be  securely  established.  The 
severity  of  the  disease  seems  to  have  little  bearing  on  the  possibility 
of  perforation,  so  that  this  calamity  is  seen  in  the  mildest,  as  well  as  in 
the  most  severe,  cases.  It  is  most  frequent  in  young  adults,  and  is 
more  common  in  men  than  in  women.  Intestinal  hemorrhage  has  no 
relation  to  intestinal  perforation,  except  in  so  far  as  the  symptoms 
of  hemorrhage  may  mask  those  of  perforation. 

The  symptoms  of  perforation  must  be  clearly  distinguished  from  the 
symptoms  of  peritonitis  from  typhoid,  because  the  two  phenomena  do  not 
coincide  in  time.  Moreover,  evidence  of  peritonitis  must  not  be  mistaken 
for  evidence  of  perforation.  Peritonitis  may  supervene  without  perfora- 
tion. It  is  improbable  that  perforation  occurs  without  peritonitis. 
The  intensity  of  the  symptoms  of  perforation  is  dependent  more  or 
less  upon  the  patient's  mental  condition,  for  his  apathy  may  fail  to 
be  stirred  by  this  alarming  catastrophe.  The  most  important  symptom 
is  pain — sometimes  sudden  and  overwhelming,  sometimes  of  gradual 
onset.  In  the  case  I  referred  to  above  there  had  been  slight  increasing 
pain  in  the  epigastrium  for  three  days,  suggesting  a  localized  peritonitis; 
but  the  perforations,  when  found,  appeared  to  be  recent.  Commonly, 
however,  pain  develops  suddenly,  when  the  patient  has  been  compara- 
tively comfortable;  it  is  sharp,  often  agonizing,  circumscribed,  usually 
located  below  the  navel,  and  somewhat  to  the  right  of  the  median  line. 
If  this  pain  persists  for  an  hour  or  more,  even  if  it  subsides  later,  it  is 
almost  conclusive  evidence  of  perforation.  Spreading  pain  indicates 
spreading  peritonitis.  Sensitiveness  usually  accompanies  the  pain, 
but,  like  the  sensitiveness  of  appendicitis,  it  is  quite  closely  limited 
to  the  area  of  the  lesion.  The  patient's  sensations  are  unreliable. 
Frequently  he  feels  suddenly  exhausted  and  prostrated;  but  this  is  not 
always  the  case.  Frequently  also  he  suffers  from  dyspnea  due  to  the 
collapse,  and  the  difficulty  of  diaphragmatic  breathing. 

The  signs  of  perforation  are  similar  to  those  of  perforation  of  the 
appendix.  There  are  the  local  signs  and  the  general  signs.  There 
are  muscular  resistance  and  spasm,  intestinal  distention,  and  delayed 
or  abolished  peristalsis.  Sometimes  there  is  evidence  of  gas  free  in 
the  abdominal  cavity,  shown  by  tympany  in  the  right  hypochondrium, 
diminishing  the  liver  dulness,  though  such  diminished  dulness  may 
also  be  due  to  gas  within  the  bowel.  Nausea  and  vomiting  are  of 
little  diagnostic  importance,  since  they  may  occur  in  typhoid  without 
perforation.  A  rapid  respiration  is  an  important  sign,  though  it  is  by 
no  means  pathognomonic  of  perforation.  The  temperature  ma}'  drop 
to  normal  or  may  rise,  though  a  marked  drop  is  less  frequent  probably 


66  THE   ABDOMEN 

than  generally  has  been  supposed.  It  is  suggestive  of  hemorrhage 
rather.  In  perforation  such  a  drop  commonly  is  succeeded  by  a  rise, 
as  peritonitis  spreads.  An  initial  chill  is  infrequent.  The  character 
of  the  pulse  is  important.  Often  it  rises  suddenly, — perhaps  20  or  30 
beats  to  the  minute, — and  it  l)ecomes  easily  compressible.  The  sudden 
rise  is  unlike  the  rise  in  hemori'hage,  which  is  slow  and  gradual.  Usually 
there  is  a  gradually  increasing  leukocytosis.  Briggs  remarks  that  in 
perforation  there  is  no  such  change  in  the  amount  of  hemoglobin  and 
in  the  number  of  red  blood-corpuscles,  as  is  seen  in  hemorrhage. 

The  diagnosis,  then^fore,  must  be  based  merely  upon  pain,  sensi- 
tiveness, muscular  rigidity,  altered  respiration,  change  in  rate  and 
quality  of  the  pulse,  and  evidence  of  shock.  In  the  differential  diag- 
nosis we  bear  in  mind  the  possibility  of  pleurisy,  pneumonia,  mesenteric 
and  iliac  thrombosis,  appendicitis,  peritonitis  from  any  cause,  intestinal 
obstruction,  adenitis,  and  cholecystitis. 

Before  going  on  to  the  important  subject  of  treatment  there  are  two 
or  three  points  in  the  pathology  which  every  practitioner  should  appre- 
ciate. The  nature  of  the  peritoneal  infection  varies  greatly,  for  the  infec- 
tion depends  upon  the  character  of  the  organisms  which  have  escaped 
from  the  bowel.  These  organisms  in  the  ileum  are  multifold.  Generally, 
however,  we  find  in  the  abdominal  cavity  the  Bacillus  coli  communis 
and  the  Bacillus  mucosus  capsulatus,  mixed  occasionally  with  sundry 
cocci.  Briggs  recalls  the  fact  that  infection  of  the  peritoneal  cavity 
may  occur  through  the  base  of  an  ulcer  without  its  perforation,  and 
quotes  loison.^  Such  cases  are  unusual.  Adhesions  occur  more  or  less 
extensively  in  nearly  all  cases.  It  is  wise  and  of  considerable  assistance 
in  making  the  prognosis  to  take  cultures  from  several  places  in  the 
abdomen;  deep  and  superficial,  when  an  operation  is  done.  It  is  sur- 
prising often  to  find  a  sterile  culture  at  the  surface  and  virulent  organ- 
isms lower  down. 

Treatment  is  by  operation.  There  is  no  satisfactory  evidence 
that  patients  can  be  saved  by  any  other  means.  Operation  is  imjjera- 
tive  always  when  the  diagnosis  of  perforation  is  made.  In  case  of  doubt, 
when  intestinal  perforation  is  suspected  only,  an  exploratory  operation 
generally  is  wise,  though  this  must  depend,  of  course,  on  the  patient's 
condition.  These  typhoid  patients  often  endure  abdominal  section 
surprisingly  well,  and  even  if  no  perforation  be  found,  the  better  chance 
has  been  taken  through  exploratory  incision.  With  proper  care  in 
dressing  the  wound  afterward,  a  return  to  routine  cold  bathing  can 
be  made  in  the  course  of  a  few  hours. 

There  has  been  debate  as  to  how  soon  after  perforation  abdominal 
section  should  be  done.  It  should  be  done  as  soon  as  the  patient  has 
rallied  from  the  initial  shock;  but  if  there  be  no  rally,  as  rarely  happens, 
operation  should  be  done  in  any  case. 

There  has  been  debate  also  as  to  the  choice  of  an  anesthetic.  As  a 
rule,  we  should  use  general  anesthesia,  preferably  ether,  and  .should 
intrust  it  to  an  experienced  anesthetist.  Local  cocain  anesthesia  is 
1  Revue  de  chir.,  Februarj'  10,  1901,  No.  2. 


TUBERCULOSIS    OF   THE    INTESTINES  67 

permissible  in  operating  upon  a  patient  in  profound  shock.  As  a  rule, 
however,  the  operation  demands  considerable  exploration  and  thorough- 
ness, which  are  difficult  or  impossible  under  local  anesthesia. 

The  incision  should  be  made  through  the  right  rectus  muscle,  below 
the  navel,  for  we  know  that  most  perforations  occur  in  the  ileum, 
which  lies  in  the  right  lower  quadrant  of  the  abdomen  and  in  the  pelvis. 
The  incision  should  be  long  enough  to  permit  comfortable  manipulation 
within  the  abdomen,  and  be  it  remembered  that  these  operations 
should  never  be  consigned  to  the  surgical  tyro.  The  cecum  should  be 
sought  at  once  as  the  guide  to  the  ileum;  then  the  last  two  or  three 
feet  of  the  ileum  should  be  carefully  overhauled,  after  which  one  should 
explore  the  cecum,  the  appendix,  the  sigmoid,  and  perhaps  a  Meckel's 
diverticulum.  It  is  unlikely  that  perforations  exist  elsewhere.  If 
they  do,  local  evidence  before  operation  will  probably  have  suggested 
an  incision  other  than  in  the  right  lower  quadrant.  Multiple  perfora- 
tions are  not  commonly  found,  but  multiple  areas  of  thinning  may  often 
be  detected  in  careful  palpation.  The  repair  of  lesions  in  the  gut  is  a 
simple  matter,  and  should  be  made  with  two  rows  of  Lembert  stitches. 
Thin  patches  not  yet  perforated  should  be  turned  in  also.  Do  not 
excise  the  ulcer.  Rarely,  if  repair  involves  dangerous  narrowing  of 
the  lumen,  the  surgeon  must  excise  portions  of  the  intestine.  Ab- 
dominal irrigation  is  of  great  importance,  and  the  stream  should  wash 
thoroughly  the  cavity  from  diaphragm  to  pelvis.  Close  the  abdominal 
wound  with  drainage,  using  a  split  rubber  tube  in  the  pelvis  and  wicks 
at  the  site  of  perforation.  If  the  patient's  heart  will  permit,  he  should 
be  put  to  bed  in  Fowler's  position,  and  he  should  be  carefully  stimulated. 
The  after-treatment  is  not  remarkable,  and  except  for  the  care  of  the 
abdominal  incision,  the  routine  typhoid  treatment  should  be  continued. 
In  giving  baths,  cold  sponging  and  fan  baths  must  suffice  for  a  few 
days,  the  wound  being  guarded  by  cotton,  rubber  protective,  and 
collodion. 

The  possibility  of  subsequent  perforations  is  always  present,  and 
should  they  occur,  the  need  of  a  second  operation  is  as  imperative  as 
before  the  first. 

Prognosis. — Without  operation  all  these  patients  die.  The  mor- 
tality with  operation  is  falling  as  physicians  and  surgeons  are  learning 
their  business.  The  mortality  depends,  of  course,  on  the  general  con- 
dition of  the  patient,  the  progress  of  the  disease,  the  time  elapsed  since 
perforation,  and  the  skill  of  the  surgeon;  but  successive  statistics  are 
showing  constant  improvement,  and  such  observers  as  Keen,  Osier, 
Harte,  Gushing,  and  Briggs  are  optimistic  enough  to  look  forward  to 
30,  50,  60,  and  even  70  per  cent,  of  recoveries. 

TUBERCULOSIS  OF   THE   INTESTINES 

Tuberculosis  of  the  intestines  presents  to  the  surgeon  a  form  of 
lesion  frequently  seen.  Experience  varies,  but  probably  this  disease 
comes  to  operation  as  often  as  does  a  perforating  typhoid  ulcer,  and 


68  THE    ABDOMEN 

the  surgeon  should  always  bear  tuberculosis  in  mind  when  lie  is  con- 
fronted with  an  obscure  abdominal  lesion. 

We  may  name  3  groups  of  tuberculous  intestinal  lesions:  (1)  The 
disseminated  form  of  tuberculosis  of  the  mucosa  without  tendency 
to  recovery;  (2)  solitary  or  multiple  ulcers  with  tendency  to  recovery; 
(3)  tuberculosis  of  the  ileocecal  region,  with  the  formation  of  a  tumor. 

The  first  form  need  not  concern  the  surgeon,  because  it  is  associated 
with  a  general  tuberculosis,  and  involves  the  intestines  so  widel}'  as 
to  render  operation  futile. 

Individual  or  associated  multiple  tuberculous  ulcers,  which  tend 
to  heal,  rarely  concern  the  surgeon  during  their  activit}'.  The}-,  too, 
are  generally  part  of  an  acute  tuberculosis,  often  pulmonarj-.  They 
do  concern  every  practitioner,  however,  in  so  far  as  they  present  a  pos- 
sible source  of  farther  infection,  and  because  they  may  be  cured  through 


Fig.  24. — Lateral  anastomosis. 

proper  measures.  Such  patients  should  have  the  out-of-doors  life 
prescribed  for  them,  and  should  be  dieted  vith  care,  eating,  in  forced 
fashion,  non-irritating  but  fat-producing  foods. 

The  sequelae  of  these  healed  ulcers  are  of  great  surgical  importance, 
because  the  sequelae  are  stenoses  of  varying  degree,  leading  up  even  to 
complete  obstruction.  Writers  have  estimated  that  25  per  cent,  of 
healed  tuberculous  ulcers  produce  stenoses. 

The  symptoms  of  such  stenoses  are  the  ordinary  sA'mptoms  of 
chronic  intestinal  obstruction,  and  the  proper  diagnosis  is  often  difficult. 
It  will  be  founded  upon  a  general  consideration  of  the  patient's  condi- 
tion. A  young  man  in  poor  health,  with  evidence  of  pulmonary  or 
other  tuberculctsis,  hectic,  running  a  low,  irregular  fe\-er.  with  distur- 
bance of  nutrition,  with  constipation  alternating  with  diarrhea,  or 
with  signs  of  total  obstruction,  belongs  to  the  type  we  are  considering. 


ACTINOMYCOSIS    OF   THE    INTESTINE  69 

The  treatment  is  by  operation.  Open  the  abdomen  in  the  median 
line,  find  the  constriction,  which  may  be  in  either  the  large  or  the  small 
intestine;  release  adhesions,  and  excise  the  affected  area.  If  the  con- 
striction is  in  the  small  intestine  or  the  transverse  colon,  end-to-end 
suture  is  permissible  to  complete  the  repair.  Do  not  use  the  Murphy 
button  in  the  large  intestine,  because  irregularities  in  the  thickness  of 
the  bowel,  troublesome  epiploic  appendages,  the  solid  character  of  the 
contents  of  the  colon,  and  a  blood-supply  less  abundant  than  in  the 
small  intestine  render  the  button-union  uncertain.  An  effective 
method  of  joining  any  portions  of  the  bowel  is  side-to-side  anastomosis, 
after  closing  completely  the  cut-off  bowel-ends  (Fig.  24).  The  after- 
treatment  is  of  the  same  painstaking  sort  I  have  described  when  speak- 
ing of  intestinal  obstruction. 

Ileocecal  tuberculosis  is  the  most  common  variety  seen  in  surgical 
practice.  It  is  associated  with  the  development  of  a  tumor  in  the 
appendix  region,  and  may  be  confused  with  appendicitis,  with  actino- 
mycosis, or  -with,  cancer  of  the  cecum.  Like  the  other  forms  of  intestinal 
tuberculosis,  it  is  usually  secondary.  The  disease  may  or  may  not 
encroach  upon  the  lumen  of  the  bowel,  but  the  bowel-wall  is  greatly 
thickened,  often  by  chronic  inflammation,  and  the  neighboring  lymph- 
nodes  frequently  are  affected.     Progress  of  the  disease  is  slow. 

The  symptoms  are  those  of  chronic  intestinal  stenosis— constipa- 
tion rather  than  diarrhea,  or  the  alternation  of  the  two,  is  the  rule — 
with  colic,  rumbling,  occasional  vomiting,  and  sometimes  visible  peris- 
talsis. There  may  be  blood  in  the  stools,  due  to  ulceration  of  the 
mucosa,  but  there  is  rarely  a  complete  obstruction.  When  the  tumor 
develops,  it  is  usually  in  the  line  of  the  colon,  and  is  hard,  nodular,  and 
frequently  visible.  It  is  not  very  tender,  and  does  not  move  with 
respiration,  though  it  may  be  shifted  by  handling  and  gives  a  dull, 
tympanitic  note  on  percussion.  The  disease  may  last  for  j^ears,  and 
under  the  best  of  conditions  may  disappear  spontaneously.  On  the 
whole,  however,  the  patient's  condition  gradually  becomes  worse,  and 
he  dies  eventually  of  wasting  general  tuberculosis  or  from  the  intestinal 
obstruction. 

The  treatment  of  this  form  of  tuberculosis  is  operative,  our  purpose 
being  to  side-track  the  disease  by  intestinal  anastomosis  if  the  condi- 
tions are  desperate  and  the  obstruction  serious;  or,  in  milder  cases,  to 
remove  the  disease,  should  it  be  susceptible  of  such  radical  treatment; 
and  be  it  remembered  that  total  extirpation  gives  the  only  reliable 
chance  of  restoring  health.  I  shall  discuss  the  method  of  removing 
this  portion  of  the  bowel  when  I  speak  of  the  removal  of  cancer  of  the 
large  intestine. 

ACTINOMYCOSIS  OF  THE  INTESTINE 

Wright,  in  his  valuable  monograph,  states  that  in  his  opinion  "the 
term  actinomycosis  should  be  restricted  in  its  meaning  to  a  suppurative 
process  combined  with  a  granulation-tissue  formation,  the  pus  of  which 
contains  the  characteristic  granules  or  'Driisen,'   composed  of  dense 


70  THE    ABDOMEN 

aggregates  of  branched  filamentous  micro-organisms,  and  of  their 
transformation  or  degenerative  products."  '  Frequently  writers  have 
confused  with  actinomycosis  sunth}-  other  conditions,  such  as  pseudo- 
tuberculosis, streptothrix,  or  cladothrix,  from  which  actinomycosis 
should  be  sharplj^  distinguished. 

The  presence  of  actinomycosis  within  the  abdominal  cavity,  and 
especially  within  the  intestine,  is  now  recognized  as  of  not  infrequent 
occurrence.  It  is  mistaken  for  tuberculosis  by  the  student.  The 
disease  is  a  chronic  inflammatory  jjrocess,  associated  with  abundant 
production  of  new  tissue,  as  well  as  with  active  tissue  destruction. 
It  njay  come  to  a  standstill  or  be  recovered  from;  or  it  may  continue 
active.  It  is  more  common  in  the  colon  than  in  the  stomach  and  small 
intestine.     It  has  been  found  in  the  appendix,  the  cecum,  and  the 


Fig.  25. — Actinomycosis,  showing  clubs. 

rectum..  It  involves  the  whole  thickness  of  the  bowel,  causes  adhe- 
sions to  the  neighboring  viscera,  attacks  all  tissues  in  its  path,  and 
finds  exit  usually  through  the  abdominal  wall.  It  presents  a  brawny 
appearance  on  the  body-surface,  with  peculiarly  bright-red  granulations 
cropping  through  and  bleeding  easily.  It  becomes  undermined,  sup- 
purates, and  discharges  pus  from  sundry  openings.  The  pus  is  usually 
thin,  less  often  stringy,  and  frequently  contains  the  characteristic 
granules.  The  parasites  ma}'  spread  throughout  the  body  b}'  the  blood- 
vessels, as  well  as  by  continuity.  They  do  not  seem  to  enter  the  lym- 
phatics; therefore  the  associated  lymph-nodes  are  probably  enlarged 
through  a  mixed  infection. 

^  James  Homer  Wright,  Puljlications  of  tlie  Massachusetts  General  Hospital, 
1905,  vol.  i,  No.  1. 


EMBOLISM   AND   THROMBOSIS    OF   THE    MESENTERIC    VESSELS       71 

S5miptoms. — The  clinical  course  is  slow.  There  are  3  periods: 
an  initial  latent  period,  a  period  of  tumor  formation,  and  a  period  of 
suppuration  and  fistula.  The  patient  suffers  at  first  with  a  varying 
intestinal  catarrh.  After  some  weeks  or  months  a  tumor  is  felt,  usually 
in  the  ileocecal  region.  It  may  or  may  not  be  movable.  Frequently 
it  is  attached  to  and  infiltrates  the  abdominal  wall.  Generally  there  is 
little  pain  or  tenderness.  At  this  stage  it  simulates  chronic  appendi- 
citis, an  abscess,  or  sarcoma.  With  the  formation  of  sinuses  and  out- 
cropping granulations  fecal  fistula  may  be  established.  Intestinal  ob- 
struction is  rare. 

Patients  fi'equently  suffer  from  malnutrition  and  exhibit  a  fluctuat- 
ing fever.  There  is  a  late  amyloid  degeneration  of  other  organs,  and 
there  may  be  a  low  percentage  of  hemoglobin.  Actinomycotic  invasion 
of  the  peritoneal  cavity  with  diffuse  peritonitis  is  seldom  seen. 

The  diagnosis  cannot  certainly  be  made  until  the  disease  breaks 
through  the  skin  or  until  the  organism  is  obtained  in  some  other  fashion. 
The  surgeon  should  suspect  the  disease,  however,  in  every  case  of 
chronic  tumor  of  the  ileocecal  region  associated  with  fever  and  mal- 
nutrition. 

The  prognosis  is  bad  if  the  disease  be  left  to  itself. 

The  treatment  is  surgical.  The  mass  of  disease  must  be  cleared 
away  with  the  knife  and  curet  so  far  as  possible.  By  this  means  granu- 
lation tissue  and  pus-pockets  are  removed  and  drained,  and  air  is 
admitted,  which  seems  to  limit  the  growth  of  the  parasite.  There  is 
no  distinct  advantage  in  extensive  operations  upon  the  intestine,  for 
it  is  difficult  to  secure  an  aseptic  field,  and,  moreover,  as  the  gut  is 
patent,  there  is  no  call  for  anastomosis  to  relieve  obstruction. 

Potassium  iodid  has  been  relied  upon  in  the  after-treatment,  and 
frequently  has  seemed  to  act  favorably  on  those  portions  of  the  disease 
which  could  not  be  removed  by  operation.  A.  D.  Bevan  advises  copper 
sulphate  in  the  treatment  of  this  disease,  and  thinks  it  valuable,  taken 
internally  and  used  as  a  wash.^ 

EMBOLISM   AND  THROMBOSIS   OF   THE  MESENTERIC   VESSELS 

It  is  difficult  to  condense  into  a  few  lines  this  important  subject — 
important  for  its  high  mortality  rather  than  for  its  frequency.  Happily, 
it  is  not  common.  The  diagnosis  is  obscure  and  difficult,  but  the 
operative  treatment  is  as  urgent  as  is  that  for  typhoid  perforation.  In 
1904  Jackson,  Porter,  and  Quinby  summed  up  for  us  the  knowledge 
of  the  subject.- 

The  cases  are  acute  and  chronic.  The  acute  cases  are  far  the  more 
numerous,  and  are  due  to  plugging,  either  of  the  arteries  or  veins,  fol- 

^  Bevan  uses  a  1  per  cent,  solution  of  copper  sulphate  injected  into  the  sinuses 
and  applied  liberally  about  the  -n-ound.  He  gives  the  drug  internally  in  doses  of 
y  to  i  grain,  three  times  daily  (communication  to  the  Society  of  Clinical  Surgerj^, 
October  5,  1905). 

-  J.  M.  Jackson,  C.  A.  Porter,  and  W.  C.  Quinby,  Mesenteric  Embolism  and 
Thrombosis,  a  Study  of  214  Cases,  Jour.  Amer.  Med.  Assoc,  June  4,  July  2,  9,  and 
16,  1904. 


72  THE   ABDOMEN 

lowed  by  infarction,  with  usually  a  bloody  exudate  into  the  bowel 
corresponding  to  the  site  of  plugging.  The  size  and  relative  importance 
of  the  vessels  occluded  determine  the  extent  of  the  infarction  and  the 
amount  of  the  exudate.  If  a  small  vessel  only  be  obstructed,  and  if 
collateral  circulation  through  the  mesenteric  loops  remain,  there  may 
be  no  bloody  exudate,  and  the  symptoms  may  be  slight;  but  such 
mild  cases  are  rare.  About  10  per  cent,  of  the  cases  are  chronic — 
that  is,  running  over  two  months.  90  per  cent,  are  acute.  Acute  cases 
are  due  to  quickly  developing  thrombosis  or  embolism  ovenvhelming 
the  nutrition  of  the  parts.  Chronic  cases  appear  to  be  due  to  a  throm- 
bosis which  makes  progress  from  time  to  time,  with  the  accompanying 
and  intervening  establishment  of  a  collateral  circulation.  There  are 
a  few  rare  cases  in  which  partial  healing  has  taken  place  through  col- 
lateral circulation. 

The  pathologic  appearances  are  various,  running  from  a  simjDle 
hyperemia  to  gangrene,  perforation,  and  peritonitis.  In  about  three- 
fifths  of  the  cases  the  infarcted  area  shows  a  line  of  demarcation.  We 
find  ulcerations  of  the  mucosa,  a  mesentery  thickened  and  edematous, 
sometimes  containing  extra vasated  blood  forming  a  palpable  tumor. 
In  a  small  percentage  of  the  cases  the  infarction  may  involve  the  whole 
small  intestine,  the  ascending  colon,  and  part  of  the  transverse  colon. 
This  indicates  closure  of  the  superior  mesenteric  artery.  Closure  of 
the  inferior  mesenteric  causes  corresponding  damage  to  the  large  in- 
testine only.  There  may  be  small  areas  of  involvement  of  the  ileum 
alone.  Subserous  hemorrhages  are  not  uncommon;  the  mesenteric 
lymph-nodes  frequently  are  swollen.  Involvement  of  the  large  intestine 
is  due  usually  to  arterial  embolism,  not  to  venous  embolism. 

The  disease  occurs  in  men  twace  as  often  as  in  women,  and  is  seen 
at  all  periods  of  life,  but  more  especially  from  middle  age  onward. 

Symptoms. — The  few  chronic  cases  need  not  detain  us.  They  are 
impos.sible  of  diagnosis  generally,  and  have  as  characteristics  occasional 
attacks  of  pain,  rumbling,  diarrhea  or  constipation,  and  cly.spepsia. 
Frequently  they  progress  until  they  exhibit  evidences  of  an  acute 
abdominal  disease.     In  rare  cases  they  cease  spontaneous!}'. 

Symptoms  of  acute  embolism  or  thrombosis  are  violent,  but  not  charac- 
teristic. Pain  is  always  present.  Generally  it  is  felt  throughout  the 
abdomen;  rarely  it  may  be  localized  in  the  epigastrium,  about  the 
umbilicus,  or  possibly  in  some  unusual  portion  of  the  abdomen.  Some- 
times it  is  of  sudden  onset,  sometimes  it  is  gradual,  but  in  any  case  it 
usually  becomes  intense  and  wearing.  Tenderness  is  present  in  about 
three  cases  out  of  four,  and  corresponds  to  the  location  of  the  pain. 
Nausea  and  vomiting  generally  are  present,  especially  when  the  attack 
of  pain  is  acute.  The  vomiting  may  be  considerable,  and  in  the  end 
may  become  stercoraceous  or  contain  clear  blood.  There  may  be  diar- 
rhea or  constipation.  There  is  no  rule,  but  the  action  of  the  bowels 
and  the  character  of  their  discharges  depends  upon  the  extent  of  the 
lesion.  Most  commonly  there  are  bloody  movements,  but  if  the  area 
of   he  disease  is  extreme,  there  will  result  obstruction,  with  obstipation. 


INTUSSUSCEPTION  73 

If  the  area  be  small,  there  may  result  normal  movements.  There  is 
almost  always  a  leukocytosis  and  an  iodophilia.  The  temperature  falls 
at  first,  and  rises  later,  with  the  onset  of  peritonitis.  The  pulse  becomes 
soft,  rapid,  and  compressible.  Sometimes  the  skin  shows  purpuiic 
spots. 

The  diagnosis  rarely  is  made  with  any  certainty.  Commonly  the 
condition  is  mistaken  for  appendicitis,  intussusception,  or  volvulus. 
Jackson,  Porter,  and  Quinby  quote  Gerhardt/  who  makes  the  following 
diagnostic  postulates: 

1.  There  must  be  present  a  source  of  the  embolus. 

2.  There  are  copious  intestinal  hemorrhages  unexplainable  by 
diseases  of  the  gut-wall  or  by  hindrance  to  the  portal  circulation. 

3.  There  is  quick  and  marked  fall  of  body  temperature. 

4.  Colicky  abdominal  pains,  which  may  be  very  severe. 

5.  Later,  distention  of  the  abdomen  and  free  fluid  occurs. 

6.  Emboli  of  other  parts  may  have  been  present  before,  or  may 
occur  simultaneously  with,  closure  of  the  mesenteric  vessels. 

7.  There  occurs  sometimes  a  large,  palpable  blood  tumor  between 
the  layers  of  the  mesentery. 

Clinically,  it  is  rare  to  find  all  these  points  established.  It  is  impos- 
sible to  differentiate  clinically  betw^een  the  closure  of  arteries  and  veins. 

The  prognosis  is  bad.  About  94  per  cent,  of  the  patients  the  if 
untreated.  According  to  the  statistics  at  command,  about  92  per  cent, 
die  when  treated. 

The  treatment  is  by  operation,  and  this  implies  resection  of  the 
affected  intestine.  The  mortality  is  due  to  profound  shock  and  septic 
infection,  and,  in  a  large  number  of  cases,  doubtless,  to  fault}"  technic 
in  not  removing  aU  the  bowel  involved.  Accurately  to  remove  all  the 
disease  is  rendered  difficult  because  frequently  there  is  no  sharp  line  of 
demarcation,  with  the  result  that  after  the  intestinal  joint  has  been 
made,  spreading  gangrene  may  persist.  In  view  of  these  facts  it  is 
advisable  to  bring  the  involved  bowel  well  outside  of  the  wound,  leav- 
ing a  liberal  margin  at  either  end.  Cut  away  the  disease,  and  fix  the 
intestinal  stumps,  carefully  protected  by  gauze,  in  the  abdominal  incision. 
A  further  spreading  of  the  gangrene  maj^  thus  be  watched  and  treated. 
If  the  patient  survive,  a  secondary  operation  is  necessary.  In  all  cases 
a  thorough  flushing  of  the  abdominal  cavity  is  recommended.  After 
the  operation  the  patient's  strength  must  be  carefully  supported  with 
stimulants,  heat,  and  rectal  feeding. 

INTUSSUSCEPTION 

Intussusception  or  invagination  may  produce  obstruction  and  even 
strangulation.  The  process  is  a  displacement  of  a  portion  of  the  intes- 
tine, by  which  the  upper  part  is  telescoped  into  the  lower.  In  some 
cases  this  relation  is  reversed.  Most  cases  of  intestinal  obstruction 
in  children  are  due  to  intussusception.  Four  varieties  of  the  disease 
1  Wiirzburg.  med.  Zeit.,  1863,  vol.  iv,  p.  141.    • 


74  THE    ABDOMEN 

are  recognized:  The  ileocolic,  in  which  the  ileum  prolapses  through 
the  ileocecal  valve;  the  ileocecal,  in  which  the  ileum  and  the  ileo- 
cecal valve  prolapse  into  the  cecum  and  colon;  the  ileal,  in  which  the 
ileum  alone  is  involved;  and  the  colic,  in  which  the  colon  alone  is  in- 
volved. The  intussuscipiens  drags  with  it  its  mesentery  into  the  in- 
tussusceptum,  and  the  symptoms  vary  according  to  the  tightness  of 
the  invagination  and  the  constriction  of  the  mesenteric  vessels.  With 
slight  pressure  the  parts  become  hyperemic  and  edematous;  with  long- 
continued  pressure,  necrosis  and  hemorrhage  take  place,  as  when  the 
mesenteric  vessels  are  thrombosed.  Accordingly,  the  cases  are  acute 
and  chronic.  Rarel}^,  spontaneous  healing  takes  place  through  auto- 
matic resection  of  the  invaginated  bowel,  with  sloughing  and  discharge. 
The  danger  of  this  acute  condition  is  great.  In  the  chronic  cases,  with 
obstruction,  but  without  strangulation,  death  results  from  malnutri- 
tion. In  the  acute  cases  of  strangulation  we  anticipate  j^erf oration  and 
peritonitis.  Even  in  those  cases  which  recover  spontaneously,  through 
automatic  resection,  there  is  danger  of  subsequent  intestinal  stricture, 
with  permanent  obstruction. 

The  symptoms  of  intussusception  are  similar  to  those  of  sundry 
other  forms  of  intestinal  obstruction.  There  are  pain,  meteorism,  and 
vomiting,  with  obstipation  if  the  obstruction  is  complete.  Frequently 
there  are  bloody  stools,  or  free  blood  may  be  passed  by  the  rectum. 
The  picture  is  similar  to  that  presented  by  mesenteric  thrombosis. 
Sometimes  a  sausage-shaped  tumor  may  be  felt. 

The  diagnosis  in  children  is  not  especially  difficult.  In  adults  it  is 
obscure.  Given  a  young  child  with  abdominal  pains,  vomiting,  disten- 
tion, and  bloody  stools,  one  will  conclude  that  intussusception  probably  is 
present.     The  much-talked-of  sausage-shaped  tumor  is  not  always  felt. 

The  treatment  generally  is  operative,  if  permanent  success  is  looked 
for,  though  palliative  measures  sometimes  are  justifiable.  Palliation 
consists  in  the  injection  of  water  high  into  the  bowel,  using  low  pressure, 
the  reservoir  being  not  more  than  3  feet  above  the  buttocks,  which 
are  elevated  somewhat  above  the  shoulders.  Occasionally,  this  measure 
has  reduced  the  intussusception,  but  it  must  be  applied  early — within 
twelve  hours — and  must  be  used  with  caution.  Even  a  low  head  of  water 
has  caused  intestinal  perforation. 

Operation  consists  in  opening  the  abdomen  in  the  median  line, 
finding  the  obstruction,  and  reducing  it,  if  possible,  by  pushing  back 
the  intussusceptum  rather  than  by  pulling  out  the  invaginated  portion. 
As  in  all  cases  of  operation  upon  strangulated  bowel,  the  surgeon  must 
assure  himself  that  the  released  gut  is  viable.  In  case  of  doubt,  re- 
section must  be  made  with  the  Murphy  button,  end-to-end  suture,  or 
lateral  joining,  according  to  the  situation  of  the  disease.  In  the  case 
of  the  common  invagination  of  ileum  into  cecum  a  lateral  joining  is 
to  be  preferred. 

Intussusception,  owing  to  the  small  area  of  bowel  involved  and  the 
gradual  nature  of  the  process,  has  a  much  lower  mortality  than  mesen- 
teric thrombosis.     Prompt  surgical  intervention  saves  a  large  proper- 


VOLVULUS  75 

tion  of  the  cases — the  earlier  the  operation  is  undertaken,  the  less 
extensive  are  the  tissue  changes  found,  and  the  more  probable  is  re- 
covery. 

VOLVULUS 

Volvulus  is  a  twist  of  the  intestine  upon  its  axis,  usually  causing 
strangulation.     Rokitansky  describes  three  forms: 

1.  A  coil  of  intestine  may  twist  through  a  half-circle  or  a  whole 
circle,  around  its  own  long  axis. 

2.  The  mesentery,  or  a  portion  of  it,  may  twist  with  the  attached 
intestine. 

3.  A  portion  of  the  intestine,  together  with  its  mesentery,  may  twist 
around  another  loop  of  intestine. 

If  more  than  370  degrees  of  twist  are  present,  symptoms  will  arise. 
The  sigmoid  flexure  is  the  part  commonly  affected,  though  the  small 
intestine  may  be  the  seat  of  trouble,  in  which  case  the  result  is  more 
dangerous  than  is  a  sigmoid  volvulus.  The  causes  of  volvulus  are  not 
clear,  though  generally  a  long  mesentery  is  a  prerequisite.  Trauma- 
tism and  a  previous  peritonitis  causing  adhesions  seem  to  be  etiologic 
factors. 

The  pathologic  appearance  depends  on  the  extent  of  the  volvulus, 
and  may  vary  all  the  way  from  a  mere  hyperemia  with  edema  to  com- 
plete obstruction,  with  strangulation  and  gangrene. 

The  symptoms  vary  also.  There  is  generally  pain,  sometimes  inter- 
mittent, sometimes  acute  and  constant.  There  are  vomiting  and  obsti- 
pation.    Rarely,  there  is  a  little  blood  from  the  rectum. 

In  many  of  the  cases  the  exact  diagnosis  can  be  made.  The  con- 
dition is  seen  most  often  in  patients  advanced  in  Hfe.  There  are  the 
symptoms  of  obstruction.  The  case  may  or  may  not  appear  alarming, 
but  the  characteristic  feature  is  the  enormous  locaHzed  early  disten- 
tion. The  involved  bowel  balloons  a  portion  of  the  abdomen;  the 
distention  is  not  uniform.  The  great  coils  frequently  can  be  dis- 
tinguished. If  vomiting  occurs,  it  is  not  often  excessive,  and  usually 
comes  on  late. 

The  prognosis  depends  upon  the  extent  and  severity  of  the  strangu- 
lation. Volvulus  of  the  small  intestine  kills  70  per  cent,  of  its  victims,^ 
as  contrasted  with  46  per  cent,  in  the  case  of  the  large  intestine. 

The  treatment  is  operative  only,  and  does  not  differ  in  principle 
from  that  for  intussusception.  Gibson  records  121  cases.  For  these 
the  following  procedures  were  employed:  Untwisting,  79;  died,  31 — 
mortality,  29  per  cent.  Resection,  16;  died,  13— mortality,  81  per 
cent.  Resection  and  artificial  anus,  5;  died,  4 — mortality,  80  per 
cent.     Artificial  anus,  15;    died,  12 — mortality,  80  per  cent. 

Such  figures  demonstrate  in  another  fashion  what  I  have  said 
already,  namely,  that  early  cases,  in  which  the  volvulus  may  be  un- 
twisted, have  a  fair  chance  of  recovery,  while  later  cases,  complicated 
with  tissue  destruction  and  requiring  severe  and  extensive  operations, 
are  far  more  fatal. 

1  C.  L.  Gibson,  ibid. 


76  THE    ABDOMEN 

INTERNAL  HERNIA 

Internal,  retroperitoneal,  or  intra-abdominal  hernise  occasionally 
are  found  causing  obstruction  and  even  strangulation.  Clinicalh-, 
these  hernise  cannot  be  diffei'entiated  from  obstructions  due  to  bands, 
and  are  rarely  made  out  before  operation.  Such  hernia?  are  found 
in  the  foramen  of  Winslow,  in  the  retroduodenal  fossse,  the  retrocecal 
fossae,  and  the  intersigmoid  fossa.  As  with  other  conditions  causing 
obstruction,  the  treatment  is  by  operation. 

IDIOPATHIC  DILATATION   OF  THE   COLON 

Idiopathic  dilatation  of  the  colon  is  rare.  It  gives  rise  to  a  train 
of  puzzling  symptoms,  is  a  cause  of  so-called  phantom  tumor,  and  mns 
a  chronic  course.' 

Dilatation  of  the  colon  usualh'  begins  in  childhood,  and  is  marked 
by  obstinate  constipation,  occasional  distention  low  within  the  abdomen, 
and  malnutrition.  As  time  passes  the  distention  becomes  pronounced, 
often  being  present  for  months,  at  times  diminishing  or  totally  subsiding, 
to  recur  later.  An  ether  examination  in  certain  cases  causes  an  abun- 
dant discharge  of  flatus  and  disappearance  of  the  tumor.  Treves  ^ 
states  that  "  in  young  children  (the  conditions)  are  due  to  congenital 
defects  in  the  terminal  part  of  the  bowel,  that  there  is  in  these  cases 
an  actual  mechanical  obstruction,  and  that  this  dilatation  of  the  bowel 
is  not  idiopathic."  It  is  probable  that  such  permanent  obstruction  is 
sometimes  the  cause  of  the  dilatation. 

The  treatment  of  these  cases  of  dilatation  must  be  palliative  at  first 
by  washings  out  through  the  rectal  tube  and  by  saline  purges.  If 
the  dilatation  persists,  however,  and  becomes  grave,  as  is  sometimes 
the  case,  an  operation  is  demanded.  In  cases  not  too  far  advanced, 
opening  the  abdomen,  draining  off  the  contents  of  the  sigmoid,  and 
fixing  it  to  the  abdominal  wall,  in  case  of  torsion,  may  suffice  for  a  cure. 
Commonl}^  however,  in  the  old  persistent  cases  more  radical  measures 
are  necessary,  and  the  treatment  must  be  by  excision  of  the  affected 
coil.  This  should  be  done  in  two  steps.  An  artificial  anus  should  be 
made  above  the  distention,  first,  by  drawing  out  the  sound  gut  and 
performing  colostomy,  the  gut  being  left  fixed  outside  of  the  abdomen. 
Later,  when  convalescence  is  established  and  the  patient's  general  con- 
dition is  improved,  the  distended  bowel  must  be  excised  and  an  anas- 
tomosis made  between  sound  intestine  and  rectum,  or  the  lower  portion 
of  the  sigmoid. 

TUMORS   OF  THE   INTESTINE 

By  far  the  most  im])ortant  and  serious  obstructions  to  the  intestines 
in  advanced  life  are  those  obstructions  due  to  tumors  of  the  intestine 

1  R.  H.  Fitz,  The  Relation  of  Idiopathic  Dilatation  of  the  Colon  to  Phantom 
Tumor,  and  the  Appropriate  Treatment  of  Suitable  Case.s  of  These  Affections  by 
Resection  of  the  Sigmoid  Flexure,  Amer.  Jour.  Med.  Sci.,  August,  1899. 

2  Lancet,  1898,  i,  276. 


TUMORS   OF  THE    INTESTINE  77 

itself,  and  the  most  common  of  these  is  cancer.^  Most  cancers  of  the 
intestine  are  found  in  the  large  bowel,  but  before  taking  up  this  im- 
portant subject,  let  us  turn  for  a  moment  to  benign  tumors  and  tumors 
of  the  small  intestine. 

Benign  tumors  of  the  intestine  are  adenoma,  lipoma,  fibroma, 
myoma,  myxoma,  angioma,  teratoma,  and  such  combinations  of  benign 
and  malignant  neoplasms  as  myosarcoma,  fibrosarcoma,  etc. 

Most  of  these  benign  tumors  may  be  found  in  almost  any  portion  of 
the  intestine  and  at  any  age,  though  they  are  commonest  in  youth. 
Sometimes  they  are  polypoid,  sometimes  they  are  large,  diffuse,  and 
fixed.  They  may  hang  down  and  obstruct  intestinal  flexures  and 
valves.  Sometimes  they  are  found  to  be  the  cause  of  invaginations. 
They  develop  from  tissues  in  the  intestine  corresponding  to  their  own 
structure.  They  may  exist  for  many  years  without  giving  rise  to 
serious  symptoms.  When  they  do  cause  obstruction  or  even  chronic 
ill  health,  they  should  be  removed — an  undertaking  usually  easy  and 
little  dangerous. 

Sarcoma  of  the  intestines  is  a  rare  affection.  Its  relation  to 
cancer  is  as  1  is  to  20.  It  may  involve  any  portion  of  the  bowel,  and 
may  occur  at  any  age,  but  most  commonly  between  thirty  and  forty. 
Most  of  the  cases  reported  have  been  in  women.  The  tumor  may 
reach  a  considerable  size  and  involve  a  great  extent  of  bowel.  It  is 
likely  to  involve  neighboring  structures,  especially  the  mesentery  and 
omentum.  Metastases  are  found  in  the  liver,  kidney,  spleen,  and 
retroperitoneal  glands.  Sarcoma  produces  stenosis  less  often  than 
does  cancer. 

The  symptoms  of  sarcoma  are  variable.  There  are  the  characteristic 
wasting,  much  more  rapid  than  in  the  slow-growing  cancer.  A  mova- 
ble tumor  sometimes  may  be  felt,  though  later  the  tumor  becomes  fixed. 
Ascites  and  metastases  are  common.  There  may  be  bloody  stools,  and,- 
rarely,  there  may  be  obstruction.  Life  seldom  is  prolonged  beyond  a 
year. 

The  diagnosis  is  difficult  on  account  of  the  rarity  of  the  disease  and 
the  similarity  of  its  symptoms  to  those  of  cancer,  the  only  striking 
difference  being  the  more  rapid  progress  of  sarcoma. 

Treatment. — In  any  case,  when  a  diagnosis  suggesting  malignant 
disease  is  made,  and  a  possibility  of  radical  removal  exists,  some 
operation  for  excision  should  be  attempted.  On  opening  the  abdomen, 
if  excision  appears  impracticable,  especially  if  symptoms  of  obstruc- 
tion are  present,  the  surgeon  should  perform  entero-anastomosis  if  the 
disease  be  high  up,  or  colostomy  if  the  disease  be  low  in  the  large 
intestine.  The  recorded  operative  mortality  of  intestinal  sarcoma  is 
high,  because  hitherto  these  cases  have  come  to  the  surgeon  too  late 
for  successful  radical  treatment. 

1  Obstruction  due  to  tumors  from  without  pressing  upon  the  bowel  must  be 
dealt  with  according  to  the  indications  of  the  case.  Generally,  an  operation  is 
indicated  for  removal  of  the  obstructing  mass.  When  this  is  impossible,  the  surgeon 
must  perform  enterostomy  should  the  obstruction  persist. 


78  THE   ABDOMEN 

Cancer  of  the  Intestine. — Cancer  is  far  more  common  in  the  large 
intestine  than  in  the  small  intestine,  and  it  is  most  common  of  all  in  the 
rectum.  Von  Mikulicz  and  Kausch  give  the  following  interesting 
figures :  "  One  hundred  cases  situated  above  the  rectum ;  in  5  instances 
the  tumor  was  in  the  small  intestine;  in  19,  in  the  cecum;  in  39  in  the 
colon  above  the  sigmoid  flexure;  in  31  in  the  sigmoid  flexure  itself, 
while  in  6  cases  the  seat  of  the  trouble  was  not  exactly  stated."  It 
appears  further  that  of  all  cases  of  cancer  of  the  alimentary  tract, 
below  the  stomach,  one-half  are  in  the  rectum.  The  proportion  of  men 
to  women  affected  is  as  3  is  to  1.  It  is  a  disease  of  middle  life.  Al- 
most invariabty  it  is  primary  and  solitary. 

Different  forms  of  cancer  of  the  bowel  occur  in  the  following  order: 
cylindric  carcinoma  with  a  glandular  structure,  medullary,  gelatinous, 
scirrhous.  Cancer  of  the  intestines  leads  early  to  ulceration,  associated 
sometimes  with  slight  hemorrhage  and  rarely  with  perforation  into  the 
peritoneal  cavity,  into  some  hollow  viscus,  or  externally.  Cancer  tends 
to  incircle  the  gut,  and  thus  to  produce  stenosis,  with  consequent  hyper- 
trophy and  dilatation  of  the  intestine  above  it.  There  may  be  acute 
obstruction.  There  may  be  invagination.  The  disease  may  extend 
by  continuity,  by  th'e  blood-vessels,  by  the  lymph-vessels,  and  by  the 
peritoneum;  but  early  metastases  are  infrequent.  It  progresses  slowly, 
and  may  run  a  course  of  several  years  without  alarming  symptoms. 
In  its  course  cancer  of  the  colon  appears  to  be  far  less  malignant  than 
cancer  of  the  rectum. 

The  symptoms  of  intestinal  cancer  are  indefinite  for  long.  There 
is  at  first  a  certain  amount  of  dyspepsia,  and  constipation  alternating 
with  diarrhea.  Such  attacks  occur  and  subside,  but  return  with 
increasing  frequency.  After  a  while  the  earlier  symptoms  become 
associated  with  abdominal  distention,  which  is  a  suspicious  sign.  There 
are  occasional  attacks  of  colicky  pain.  Later  in  the  disease  periods 
of  obstruction  become  absolute,  with  great  distention  and  vomiting. 
Even  the  most  pronounced  obstruction  may  subside,  however,  perhaps 
through  ulcerations  rendering  patent  the  obstructing  mass.  Finally, 
such  symptoms  of  ileus  occur  as  have  been  described  in  the  early  pages 
of  this  chapter.  There  may  be  a  sudden  attack  of  peritonitis,  or 
symptoms  of  involvement  of  other  organs — the  bladder,  uterus,  or  liver. 
A  tumor  is  not  always  felt.  It  may  not  be  found  until  late  in  the 
disease,  or  it  may  be  discovered  early,  for  its  detection  depends  upon 
the  site  of  the  growth.  If  the  cancer  originates  in  the  posterior  wall 
of  the  bowel,  it  may  grow  to  a  considerable  size,  and  give  rise  to  serious 
symptoms  before  it  becomes  palpable.  On  the  other  hand,  a  small 
cancer,  situated  on  the  anterior  surface  of  the  cecum,  may  be  detected 
before  the  symptoms  of  its  presence  are  conspicuous.  These  tumors 
feel  hard  and  nodular,  and  may  or  may  not  be  tender;  they  may  give 
rise  to  characteristic  stools  containing  pus  and  blood,  and  the  discharges 
will  have  a  foul,  gangrenous  odor,  and  carry  necrotic  fragments  if  there 
is  an  extensive  ulceration.  The  growth  is  not  painful  in  itself,  but 
such  pain  as  there  is,  which  may  be  excessive,  is  due  to  obstruction. 


TUMORS   OF  THE    INTESTINE  79 

adhesions,  inflammations,  or  spreading  ulcerations.  With  low-lying 
cancer  there  may  be  distressing  rectal  tenesmus.  Ascites  develops 
after  the  growth  has  involved  the  serosa. 

The  diagnosis  of  cancer  of  the  intestines  is  founded  on  the  age  of 
the  patient,  wasting,  dyspepsia,  and  symptoms  of  obstruction  with 
periods  of  distention.  The  recognition  of  blood  in  the  stools  is  highly 
important,  and  the  most  minute  traces  of  blood  should  be  searched 
for  repeatedly  through  careful  chemical  tests.  The  detection  of  a 
tumor  is  confirmatory  usually.  It  is  not  always  possible  to  ascertain 
the  site  of  the  disease,  unless  a  tumor  be  made  out  or  the  location  of 
the  obstruction  be  apparent.  Artificial  distention  of  the  bowel  with 
air  or  water  is  an  important  aid,  for,  as  I  have  said  on  a  previous  page, 
the  unobstructed  large  intestine  of  an  adult  should  contain  six  quarts 
of  fluid.  Pelvic  examination  sometimes  helps.  It  is  not  always  easy 
to  distinguish  cancer  of  the  transverse  colon  and  its  flexures  from 
malignant  disease  of  other  organs  above  the  navel.  In  making  the 
diagnosis  one  observes  the  extent  of  the  distention,  the  nature  of  the 
vomiting,  and  the  amount  of  fluid  which  may  be  injected  into  the 
bowel.  In  making  a  prognosis  one  recalls  that  the  disease  runs  a 
chronic  course — sometimes  as  long  as  two  to  four  years,  if  involvement 
of  other  organs  does  not  take  place,  and  especially  if  relief  be  afforded 
by  an  artificial  anus.  The  lower  down  in  the  bowel  the  disease  is  found, 
so  much  the  longer  proportionately  will  be  its  course,  if  we  except  cancer 
of  the  rectum. 

The  treatment  of  cancer  of  the  intestines  is  operative,  even  though 
the  operation  be  but  palliative.^  In  these  cases,  however,  as  in  nearly 
all  cases  of  internal  cancer,  one  should  inform  the  patient  or  his  friends 
of  the  extreme  liability  to  recurrence  in  case  of  excision,  and  of  the 
dangers  residing  in  all  radical  procedures.  Cases  of  intestinal  cancer 
are  bad  ''surgical  risks."  The  patient's  condition  is  poor;  his  meta- 
bolism and  nutrition  are  defective;  his  vitality  is  greatly  diminished; 
he  is  prone  to  cardiac  collapse,  and  is  especially  subject  to  toxemia. 
Except  in  the  case  of  patients  seen  early,  and  in  the  robust,  radical 
procedures  generally  are  futile  and  merely  hasten  the  inevitable  end. 
Perhaps  wisely  the  majority  of  patients  afflicted  with  intestinal  cancer 
choose  the  euthanasia  which  morphin  provides. 

From  the  preceding  statements  one  sees  that  there  are  three  types 
of  contraindications  to  operating: 

1.  A  condition  of  the  patient  so  bad  that  he  cannot  withstand  the 
shock  of  operation. 

2.  A  certainty  that  radical  operation  is  impossible  on  account  of 
metastases;  an  unfavorable  position  of  the  tumor;  or  extensive  adhesions. 

3.  Wide-spread  metastases  and  ascites,  rendering  useless  a  palliative 
operation  even. 

When  it  is  possible,  a  radical  operation  should  be  done,  and  not  a 

^  Incurable  cancer  of  the  intestines  often  may  be  greatly  relieved  by  a  long  course 
of  compound  solution  of  iodin,  administered  in  increasing  doses  from  five  drops 
upward.     (See  foot-note,  p.  848.) 


80  THK    ABDOMEN 

palliative  operation,  because  the  late  appearance  of  metastases  and 
the  frequent  mobility  of  the  tumor  render  its  safe  and  complete  removal 
possible  in  the  early  stages.  The  method  of  resecting  a  tumor  of  the 
small  intestine  needs  no  comment.  The  operation  is  simple  and  direct, 
such  as  I  have  described  earlier  in  this  chapter,  when  discussing  re- 
section of  the  gut.  Kemoval  of  a  tumor  of  the  large  intestine  is  a 
more  difficult  matter,  as  the  union  of  the  cut  edges  is  less  ready  there, 
owing  to  the  inferior  blood-supply,  the  presence  of  epiploic  appendages, 
and  a  short  or  absent  mesentery,  with  a  gut  only  partiall}-  covered  by 
peritoneum.  So  it  has  come  about  that  surgeons  prefer  to  do  certain 
of  these  radical  excisions  in  two  or  three  separate  steps.  Von  Mikulicz 
has  taught  an  admirable  procedure,  applicable  especially  to  resections 
of  the  sigmoid.  To  quote  the  words  of  W.  J.  Mayo:^  "It  consists  in 
drawing  the  affected  part  out  of  the  abdomen,  and,  after  separating 
its  mesentery  and  suturing  the  two  limbs  together,  attach  it  to  the 
abdominal  incision,  with  the  diseased  part  projecting  beyond  the  skin. 
After  waiting  as  long  as  the  condition  of  the  patient  will  permit  for 
adhesions  to  protect  the  wound,  the  obstruction  is  relieved  by  a  small 
opening  in  the  distended  loop.  In  from  two  to  four  days  the  entire  pro- 
jecting area  is  cut  away,  leaving  the  two  ends  of  the  colon  flush  with 
the  skin,  side  by  side,  like  a  double-barreled  gun.  At  the  end  of  two 
weeks  a  clamp  is  introduced,  one  blade  in  each  opening,  and  made  to 
grasp  the  opposed  walls  of  the  intestine,  where  they  are  held  by  the 
sutures  for  a  distance  of  not  less  than  three  and  a  half  inches.  The 
clamps  are  gradually  tightened  until  they  cut  their  way  through, 
which  takes  from  four  to  six  days.  This  reestablishes  the  communica- 
tion. The  fistula  gradually  contracts,  and  will  cither  close  itself,  or  can 
readily  be  closed  by  secondary  plastic  operation." 

McGraw  has  recommended  that  the  new  limien  be  completed  by 
the  insertion  of  an  elastic  ligature  which  A\ill  cut  through  in  four  or 
five  days  and  estal^lish  an  anastomosis  between  the  two  limbs  within 
the  abdominal  cavity.  Von  Mikulicz's  second  step  is  taken  ten  days 
or  two  weeks  after  the  first.  By  that  time  the  patient  has  recovered 
from  the  previous  operation,  the  inflammatoiy  reaction  has  subsided, 
the  peritoneal  cavity  is  shut  off,  and  the  intestine  has  been  thoroughly 
drained. 

Cancer  of  the  ileocecal  region  may  be  removed  with  less  difficulty 
than  cancer  of  the  sigmoid,  for  the  blood-vessels  of  the  ileocecal  region 
are  terminal.  Moreover,  the  contents  of  the  ileum  and  caput  are  fluid, 
so  that  the  mechanical  problem  of  resection  is  simpler  than  in  the 
large  intestine,  where  solid  fecal  masses  endanger  the  security  of  the 
suture  line.  Furthermore,  the  arrangement  of  the  lymphatics  of  the 
large  intestine  favors  resection.  The  nodes  are  infrequent,  and  are 
invaded  late  in  the  disease.  More  than  one-half  of  the  patients  with 
cancer  of  the  colon  die  from  obstruction  of  the  intestine  before  glandular 
metastasis  has  taken  place. 

1  W.  J.  Mayo,  Resection  for  the  Relief  of  Intestinal  Obstruction,  Jour.  Amer. 
Med.  Assoc,  September  14,  1907. 


TUMORS   OF   THE    INTESTINE  81 

Resection  of  the  ileocecal  ])ortion  should  l)e  made  to  include  the 
whole  of  the  ascending  colon;  and,  conversely,  resection  of  the  ascend- 
ing colon  should  be  made  to  include  the  cecum.  After  removing  the 
ileocecal  portion  or  the  ascending  colon,  which  should  be  done  as  a 
primary  operation,  the  surgeon  should  proceed  at  once  to  a  reestablish- 
ment  of  the  intestinal  canal,  and  this  is  best  accomplished  by  lateral 
anastomosis,  the  ends  of  the  cut-off  bowel  being  previously  crushed, 
tied  off  with  catgut,  and  turned  in  with  a  purse-string  suture.  Do 
not  use  the  Murphy  button. 

The  transverse  colon  may  be  resected  in  much  the  same  way,  but 
the  surgeon  should  not  forget,  when  resecting  the  transverse  colon, 
that  in  four-fifths  of  the  cases  the  middle  coHc  arteiy  is  its  only  source 
of  blood-supply.  This  artery,  with  its  branches,  should  be  preserved 
so  far  as  possible.  In  restoring  the  canal  one  may  employ  end-to-end 
anastomosis,  as  in  the  case  of  the  small  intestine,  because  the  transverse 
colon  is  completely  surrounded  with  peritoneum,  and  is  enveloped  in 
the  folds  of  the  omentum.  Do  not  use  the  Murphy  button,  because  there 
may  be  occasionally  large  obstructing  fecal  masses  deposited  in  this 
portion  of  the  large  intestine. 

The  after-treatment  of  cases  of  intestinal  resection  is  of  no  little 
importance.  The  patient  should  be  held  in  the  semi-upright  position, 
in  order  that  any  septic  products  may  gravitate  to  the  pelvis.  Fig. 
130  in  Chapter  YIII  shows  an  admirable  apparatus  by  which  the  patient 
may  be  held  comfortably  in  Fowler's  position.  In  this  position  also 
the  continuous  rectal  infusion  of  salines  is  most  satisfactorily  given. 
Furthermore,  if  there  be  tendency  to  prolonged  nausea  or  vomiting, 
the  patient's  stomach  should  be  repeatedly  emptied,  and  irrigated  with 
hot  water. 

Palliative  operations  are  justifiable  when  radical  excision  is  im- 
possible. They  are  done  to  relieve  progressive  stenosis,  which  may 
render  intolerable  the  life  of  the  patient.  We  are  assuming,  of  course, 
that  the  patient  is  in  condition  to  bear  a  palliative  operation,  and  we 
recognize  three  such  operations:  The  first  is  the  most  serious  of  all: 
the  eliviination  of  the  intestine,  by  which  we  close  off  the  affected  por- 
tion of  the  bowel,  leaving  the  tumor  in  place,  and  then  bring  together 
by  anastomosis  sound  gut,  above  and  below  the  mass.  The  second 
palliative  operation  is  enter o-anastomo sis,  which  merely  side-tracks  the 
infected  intestine,  but  does  not  close  it  off;  and  the  third  method  is  the 
establishment  of  an  artificial  anus^ — that  is,  drawing  out  of  the  abdo- 
men the  bowel  above  the  tumor,  and  fastening  it  in  place,  so  that  the 
fecal  stream  shall  be  discharged  externally  at  this  point. 

These  palliative  operations  themselves  are  not  devoid  of  danger, 
and  the  mortality  risks  are  in  the  order  of  the  operations  named.  Of 
course,  statistics  of  such  risks  are  relative,  and  depend  upon  the  ability 
of  the  reporting  surgeon ;  the  general  condition  of  the  patient ;  and  the 
extent  of  the  disease.  Wolfler's  statistics  in  1S96  showed  a  mortality 
of  40  per  cent,  from  resections;  von  Mikulicz's  statistics  have  given  a 
mortality  of  12.4  per  cent.     The  mortality  from  palliative  operations 

6 


82  THE    ABDOMEX 

varies  also,  and,  among  others,  de  Bovis  has  reported  for  the  elimina- 
tion of  the  intestine  a  mortality  of  33  per  cent.;  for  entero-anastomosis, 
28  per  cent.;   for  enterostomy,  39  per  cent. 

Cancer  of  the  intestine  can  be  cured,  for  von  Mikulicz,  Korte,  and 
Mayo  have  recorded  the  cases  of  patients  hving  more  than  four  years 
after  extirpation  of  the  growth;  and  palliative  operations  must  be  re- 
garded as  justifiable,  since  we  see  patients  living  two,  three,  and  even 
four  years  after  colostomy.  The  average  length  of  life  after  colostomy 
is  twenty-one  months;  after  entero-anastomosis,  eight  and  a  half  months. 

The  after-treatment  in  case  of  all  these  operations  does  not  differ 
materially  from  that  described  previously  in  the  discussion  of  section 
of  the  bowel  for  other  causes — absolute  rest,  stimulants,  abstinence 
from  food  for  at  least  a  week,  except  in  the  case  of  colostomy,  and 
nutrient  enemata  given  with  special  care  when  the  operative  field  lies 
low  in  the  bowel.  These  patients  demand  abundance  of  water,  which 
may  be  given  at  first  in  a  vein  or  under  the  breast,  but  after  the  first 
day  may  be  allowed  freely  by  mouth. 

FECAL  FISTULA   AND  ARTIFICIAL  ANUS» 

Fecal  fistula  is  a  subject  of  ancient  interest  to  physicians.  Descrip- 
tions of  this  condition  are  found  throughout  our  literature,  and  the  topic 
must  be  regarded  from  the  points  of  view  of  both  detriment  and  ad- 


y^^,,,^^^ —  —  — -.--^^ 

Fig.  26. — Fecal  fistula. 

vantage.  These  fistulae  occur  as  the  result  of  di.sease  or  operation,  on 
the  one  hand,  or,  on  the  other,  they  are  purposely  and  artificially  created 
by  the  surgeon  to  relieve  disease. 

Fecal  fistulae  may  form  between  the  bowel  and  an  adjacent  hollow 
organ,  or  they  may  form  between  the  bowel  and  the  abdominal  wall 
and  perforate  the  skin.  Sometimes  the  former,  or  internal  fistulae, 
give  no  symptoms  of  inconvenience;  for  in-stance,  when  the  anastomosis 
is  between  the  gall-bladder  and  the  bowel,  or  between  the  stomach  and 
the  small  intestine;  at  other  times  serious  inconvenience  results,  as 
when  the  anastomosis  is  between  the  bowel  and  the  urinan,'  bladder. 
The  troublesome  internal  fistula  must  be  dealt  with  by  separating  the 
adherent  viscera  and  sewing  up  the  rents. 

1  Fistula  in  ano  is  not  included  in  this  section. 


FECAL    FISTULA    AND    AKT1FICL\L    ANUS 


83 


The  diagnosis  of  all  these  internal  fistula^  must  depend  on  finding 
fecal  discharge  from  the  organ  secondarily  affected,  as  from  the  uterus, 
the  vagina,  the  bladder,  etc. 

The  spontaneous  external  fistulse,  however,  are  commonly  meant 
when  we  speak  of  fecal. fistula.  They  may  be  due — (1)  To  penetrating 
wounds  injuring  the  intestine,  with  a  resulting  adhesive  inflammation 
and  an  opening  left  between  the  interior  of  the  bowel  and  the  outer 
world;  (2)  to  an  incarcerated  hernia,  w^hich  has  become  gangrenous 
and  has  perforated  externally,  leaving  a  permanent  fistula;  (3)  or 
internal  fistulse  may  follow  ulceration  of  the  bowel  from  tuberculosis, 
cancer,  actinomycosis,  or  appendicitis;  (4)  disease  of  organs  or  of  the 
abdominal  wall  may  involve  the  intestines  and  result  in  a  permanent 
fistiila;  (5)  perhaps,  most  common  of  all,  fecal  fistulse  may  follow 
surgical  operations  undertaken  for  appendicitis,  cancer,  salpingitis, 
or  any  disease  involving  the  bowel-wall,  and  necessitating  opening  or 
resecting  the  intestine. 


Intestine 


Fig.  27. — Artificial  anus. 


Spontaneous  fistulse,  formed  as  I  have  described,  may  heal  spon- 
taneously, or  they  may  remain  indefinitely.  The  commonly  permanent 
fistulse  are  those  due  to  disease.  Fistulse  due  to  traumatism  or  opera- 
tions often  heal,  even  after  months.  If  they  have  not  closed  in  three 
months,  and  if  the  patient's  streng-th  permit,  an  operation  for  their 
closure  should  be  undertaken. 

We  recognize  anatomically  two  forms  of  fecal  fistula:  First,  those 
which  communicate  with  the  outside  world  through  a  tortuous  track, 
involved  in  adhesions  and  newly  formed  connective  tissue;  second, 
those  in  which  the  bowel  is  immediately  adherent  to  the  abdominal 
wall,  while  through  the  opening  the  interior  of  the  intestine  may  be 
seen.  The  second  variety  of  fistula  is  lined  often  wath  mucosa  con- 
tinuous with  the  skin  and  intestinal  mucosa — a  mucous  fistula,  which 
does  not  heal  spontaneously.  The  first  variety  rather  than  the  second 
is  likely  to  heal  if  let  alone. 

The  symptoms  and  signs  of  fecal  fistula  are  a  discharge  of  a  part  or 
all  of  the  intestinal  contents  through  the  opening,  and  more  or  less 


84 


THE    ABDOM?]N 


malnutrition,  which  depends  upon  the  site  of  the  bowel  perforation. 
If  the  upper  part  of  the  ileum  or  the  jejunum  be  tapped  by  a  fistula, 
and  any  considerable  portion  of  the  bowel  contents  escape,  the  patient 
may  suffer  seriously  from  wasting,  and  the  acrid  discharge  will  set  up 
a  troublesome  dermatitis.  Fecal  fistula  from  the  colon  does  not  interfere 
seriously  with  the  body's  nutrition,  Ixit  it  is  gravely  annoying,  owing 
to  the  constant  discomfort  of  an  offensive  discharge. 

Ariificial  anus  must  be  distinguished  from  fecal  fistula.  Artificial 
anus  usually  is  formed  purposely  by  the  surgeon,  though  in  rare  cases 
it  may  arise  spontaneously.  It  is  an  anus — a  terminal  vent  of  the 
intestinal  canal,  where  the  bowel  comes  to  the  surface  and  discharges 


Fig.  28. — Operation  for  fecal  fistula  or  artificial  anus  (after  Bickham). 

all  its  contents.  It  leaves  collapsed  the  portion  of  intestine  below. 
Commonly,  the  surgeon  forms  it  for  the  purpose  of  shunting  off  per- 
manently the  fecal  stream  above  an  old  obstructing  cancer.  In  a 
subsequent  paragraph  I  shall  describe  the  method  of  constructing  it. 

The  treatment  of  fecal  fistula  is  to  close  it  by  operation.  To  do  this 
successfully  and  rationally  one  must  open  the  abdomen,  and  make 
a  lozenge-shaped  incision  surrounding  and  cutting  out  the  fistula.  The 
fistula,  with  its  attendant  loop  of  bowel,  is  then  drawn  outside  the 
abdominal  cavity,  and  a  portion  of  bowel  corresponding  somewhat 
to  the  excised  skin  is  removed,  leaving  a  longitudinal  slit.  Close  this 
slit  in  the  bowel  with  a  double  row  of  Lembert  stitches,  and  return 
the  gut  to  the  peritoneal  cavity.     The  abdominal  wound  is  sewed  up, 


FECAL    FISTULA    AND    ARTIFICIAL    ANUS 


85 


leaving  a  small  drain  down  to  the  injured  intestine.     The  drain  may 
be  removed  in  forty-eight  hours. 


Fig.  29. — Operation  for  remote  fecal  fistula.     Step  1:  showing  wide  skin  dissection. 

r 


Fig.  30. — Step  2  :   Skin-flap  retracted,  line  of  incision  in  muscle. 

All  fistulse  may  not  be  dealt  with  so  easily,  owing  to  a  tortuous 
channel  adhering  to  and  involving  various  structures.     In  such  case 


86 


THE   ABDOMEN 


the  surgeon  may  open  the  abdomen  at  a  point  outside  of  the  area  im- 
mediately affected,  may  search  for  the  afferent  and  efferent  hmbs 
leading  to  and  from  the  fistula,  may  resect  them,  and  unite  their  cut 
ends  to  each  other,  or  may  treat  them  by  entero-anastomosis.  In 
either  case  the  side-tracked  intestine  must  be  closed  up  lest  it  serve 
as  a  pouch  for  fecal  accumulations  which  will  keep  the  fistula  open. 
The  after-treatment  of  these  cases  does  not  differ  from  that  given  to 
any  case  of  enterectomy. 

The  formation  of  artificial  anus  may  be  accomplished  V)y  sundry 
methods,  but  in  all  the  surgeon's  effort  must  be  to  provide  for  complete 
evacuation  of  the  intestine  through  the  artificial  anus.     Owing  to  the 


Fig.  31. — Kocher's  method.     Artificial  anus. 


frequenc}'  of  malignant  obstruction  in  the  rectum  and  sigmoid  flexure, 
the  descending  colon  or  upper  portion  of  the  sigmoid  is  the  portion  of 
bowel  commonly  selected  for  artificial  anus. 

Various  attempts  have  been  made  to  provide  a  sphincter  for  the  new 
anus  by  utilizing  the  abdominal  and  thigh  muscles,  but  no  method 
has  proved  entirely  satisfactory.  I  recommend  Kocher's  method: 
Make  a  cut  on  the  left  side,  about  four  inches  long,  through  skin  and 
fascia,  two  finger-breadths  above,  and  parallel  to,  Poupart's  ligament. 
Splint  the  fibers  of  the  internal  oblique  and  transversalis  muscles,  as  in 
the  McBurnev  incision.     Retract  and  divide  the  fascia  transversalis. 


THR    MESENTERY    AXD    OMENTUM  87 

Open  the  parietal  peritoneum  and  draw  its  edges  well  outside  the  wound, 
so  that  they  form  a  fumiel.  Through  the  funnel  draw  out  a  loop  of  the 
bowel  selected,  and  stitch  it  to  the  edges  of  the  open  peritoneum  out- 
side of  the  abdominal  wall.  Close  the  skin-wound  about  the  protiiiding 
intestine.  It  is  well  not  to  open  the  bowel  at  once,  but  to  leave  it  for 
from  two  to  four  da}s,  to  fomi  adhesions  in  its  new  position.  Then 
open  the  afferent  portion,  preferably  with  the  cautery.  The  abdominal 
muscles  will  form  a  sphincter  for  the  control  of  feces,  and,  with  a  sup- 
plementary dressing  and  padded  truss,  will  provide  the  patient  with 
a  fairlv  satisfactorv  anus. 


THE  MESENTERY  AND  OMENTUM 

Injuries  and  diseases  of  the  mesentery  and  ovientum  deserve  a  word  of 
notice.  Incidentally,  I  have  spoken  of  traumatism  of  the  mesenteiy, 
and  we  have  considered  at  some  length  mesenteric  thrombosis.  There 
are,  moreover,  sundry  tumors  of  the  mesenteiy  occasionally  to  be 
found — malignant  tumors  and  benign  tumors,  as  well  as  cysts.  The 
tumors  may  remain  latent  for  years,  or  they  may  give  rise  to  sj-mptoms 
due  to  pressure  upon  organs  or  to  obstruction  in  the  intestinal  circula- 
tion. 

The  diagnosis  rarely  can  be  made,  but  one  should  operate  for 
tumor  or  obstruction  and  be  governed  by  what  he  finds.  The  question 
of  vital  importance  in  all  operations  upon  the  mesentery  is  that  of 
possible  damage  to  the  intestinal  circulation.  If  the  removal  of  a 
mesenteric  tumor  is  inevitable  and  involves  destruction  of  vessels,  the 
corresponding  portion  of  the  intestine  must  be  resected. 

The  omentum,  being  covered  with  peritoneum,  is  subject  to  those 
diseases  which  involve  the  peritoneum.  It  shares  frequently  also  in 
diseases  of  the  organs  which  it  overlies.  One  finds  in  the  omentum 
cancer  spreading  from  the  intestine,  tuberculosis,  actinomycosis.  It 
becomes  inflamed  and  gangrenous.  It  may  be  involved  in  herniae,  and 
be  constricted  and  necrotic.  It  may  contain  within  itself  tumors  of 
great  size.     It  may  become  twisted  and  strangulated. 

These  vaiying  conditions  give  rise  to  varv'ing  symptoms,  which 
rarely  may  be  diagnosticated  with  certainty.  The  only  possible  treat- 
ment is  by  operation  and  removal  of  the  affected  omentum.  Tumors 
must  be  excised;  gangrenous  and  strangulated  portions  must  be  re- 
moved. Operations  for  removal  of  portions  of  the  omentum  are  ex- 
tremely common,  but  there  is  one  point  of  importance  in  the  technic. 
The  affected  omentum  must  not  be  tied  off  en  jnasse,  but  a  series  of 
Hgatures  overlapping  each  other  must  be  passed  through  the  portion 
of  healthy  omentum  above  the  disease,  and  secured  separately,  in  order 
to  insure  perfect  hemostasis — a  difficult  matter  often  in  the  sHppeiy 
and  elusive  substance  of  the  fatty  omentum. 

So  much  for  the  intestines  and  their  appendages.  It  is  difficult  for 
the  student,  or  for  the  experienced  practitioner,  to  separate  the  cHseases 
we  have  been  considering  from  diseases  of  other  abdominal  organs,  of 


88  THE   ABDOMEN 

which  the  lesions  may  complicate  or  simulate  diseases  of  the  intestines. 
Constantly  the  reader  must  be  bearing  in  mind  the  fact  that  few  of 
these  intestinal  disease  processes  appear  as  distincti\'e  entities.  Varie- 
ties of  symptoms  overlap  and  interlace.  Varieties  of  signs  mislead  and 
confuse.  Anatomic  relations  are  indefinite,  shifting,  puzzling.  Gradu- 
ally, as  he  studies,  the  reader  will  perceive  that  the  conglomerate  mass 
of  abdominal  organs,  whether  normal  or  diseased,  begin  to  arrange 
themselves  in  their  logical  relations  and  positions.  Sometimes  he  may 
see  special  organs  and  special  diseases  standing  apart  from  their  fel- 
lows.   In  this  chapter  we  have  dealt  with  such  independent  diseases. 


CHAPTER  III 


THE  RECTUM  AND  ANUS 

After  the  reader  has  gained  a  general  acquaintance  with  diseases 
of  the  intestines,  his  curiosity  will  lead  him  to  inquire  about  the  terminal 
portion  of  the  gut — the  rectum  and  the  anus.  A  knowledge  of  these 
parts  is  essential  to  an  understanding  of  intestinal  disease,  for  anatomic 
and  functional  disturbances  of  the  terminal  portion  of  the  canal  are 
closely  associated  with,  and  simulate  or  mask,  diseases  of  the  intestines 
proper.     For  example,  constipation  and  diarrhea  are  conditions,  the 


Rectal  valves  (Martin). 


cause  for  which  must  be  sought  in  all  portions  from  gullet  to  anus. 
Obstructions  may  be  high  in  the  duodenum  or  low  in  the  rectum,  and 
peritoneal  infection  may  arise  from  lesions  in  any  part  of  the  alimentary 
tract. 

Inflammations  and  new-growths  are  causes  of  rectal  disturbance 
as  commonly  as  they  are  causes  of  intestinal  disturbance,^  but  the 
rectum  is  subject  to  tico  special  conditions  which  are  seldom  found  in  the 
upper  reaches  of  the  gut — disturbances  of  circulation,  leading  to  venous 
engorgement  and  hemorrhoids;  and  congenital  malformations,  extend- 
ing sometimes  to  complete  occlusion. 

89 


90 


THE   ABDOMEN 


Surgery  of  the  rectum  in  patients  of  all  ages,  from  birth  to  ad- 
vanced years,  concerns  the  student,  and  the  first  condition  of  interest 
is  that  of — 

HYPERTROPHY  OF  THE  RECTAL  VALVES 

These  valves,  normally  three  in  number,  are  commonly  called 
Houston's  valves,  and  their  proper  function  is  to  control  the  descent 
of  fecal  masses  into  the  rectum.  Hypertrophy  of  these  valves  may 
be  so  extensive  as  to  interfere  seriously  with  the  movements  of  the  bowels, 
or  as  to  cause  an  almost  complete  obstioiction  even.  A  great  many 
cases  of  hypertrophy-  of  Houston's  valves — when  the  h}-}Dertrophy  is 
an  inflammatory  or  congestive  process — may  be  relieved  by  touching 
the  injected  mucosa  through  the  proctoscope  with  a  5  per  cent,  solution 
of  silver  nitrate,  taking  care  to  cover  an  area  no  larger  than  a  ten-cent 
piece,  to  wash  out  the  rectum  at  once  with  a  nonnal  saline  solution, 
and  to  leave  the  affected  area  well  powdered  with  sodium  bicarbonate. 
If  this  simple  treatment  fails  to  relieve  the  disorder,  the  surgeon  may 
cut  down  the  edge  of  the  valves. 

IMPERFORATE  ANUS 

It  is  the  duty  of  the  practitioner  to  examine  carefully  a  new-bom 
child  after  delivery,  in  order  to  ascertain  congenital  defects.  In  a 
certain  proportion  of  cases  he  will  find  that  there  is  no  anal  opening. 


ABC 

Fig.  33. — Imperforate  anus:  .4,  Thick  layer  of  tissue  inter\'ening  between  the 
rectum  and  the  site  of  the  anus;  B,  occlusion  of  the  rectum;  C,  imperforate  rectum 
(Esmarch). 


or  that  the  anal  canal  ends  shortly  in  a  blind  pouch.  The  sphincter 
and  levator  ani  muscles  are  properly  developed,  but  the  rectum  does  not 
communicate  with  the  anus. 

There  are  three  types  of  imperforate  anus  and  rectum:  (1)  That 
simple  type  in  which  the  bowel  comes  down  to  the  sphincter  and  is 
separated  from  the  skin  by  a  thin  membrane  only;  (2)  the  form  in 
which  the  anal  dimple  is  seen,  but  is  separated  by  an  appreciable  distance, 
measured  in  inches,  from  the  end  of  the  gut;  (3)  the  form  in  which 
the  bowel  empties  through  a  fistula  into  the  genito-urinary  tract, 
bladder,  urethra,  vagina. 


IMPERFORATE   ANUS 


91 


Imperforate  anus  is  clue  to  failure  of  proper  fetal  development, 
and  the  symptoms,  after  birth,  are  striking  and  almost  immediate, 
varying  with  the  nature  of  the  abnormality.  If  the  rectal  obstruction 
be  complete,  there  wiU  result  a  failure  to  pass  meconium;  with  this 
there  are  associated  abdominal  distention,  colic,  lack  of  appetite, 
vomiting,  malnutrition,  and  death.  If  the  bowel  open  into  the  genito- 
urinaiy  tract,  feces  will  be  passed  by  the  urethra  or  vagina,  and  the 
symptoms  of  intestinal  obstruction  will  be  slight  or  entirely  absent. 
Under  these  circumstances  the  child  may  survive  to  maturity  even,  but 
in  addition  to  the  intense  discomfort  of  the  unnatural  condition  and  its 
disgusting  evidences,  there  is  always  present  the  danger  of  septic  infec- 
tion of  the  kidneys  and  genital  organs.  Most  of  these  fistula  cases 
die  in  a  few  months,  however,  unless  relieved  by  operation. 

The  only  treatment  is  by  operation.  The  procedures  are  interesting 
and  various.  The  first  and  simplest  form  of  imperforate  anus  is  easily 
remedied;  but,  unfortunately,  the  simplest  condition  is  not  the  common 
condition.     When  a  diaphragm  of  thin  membrane  only  separates  the 


A  B  c 

Fig.  34. — Imperforate  anus  T\-ith  different  cloacal  openings  (male):  A,  Terminat- 
ing in  bladder;  B,  terminating  in  the  urethra;  C,  terminating  at  the  meatus 
(Esmarch). 


bowel  from  the  skin,  meconium  may  be  seen  through  it,  or  an  impulse 
may  be  felt  when  the  child  cries.  In  such  case  rupture  with  the  finger 
or  aspiration  of  the  bowel  through  the  anus,  and  drainage  for  a  few"  days 
with  catheter  or  gauze,  will  establish  a  cure,  care  being  taken  that  the 
opening  is  kept  patent  by  daily  stretching.^ 

The  second  type  of  imperforate  anus  is  far  more  difficult  of  treat- 
ment, and  the  mortality  is  far  higher.  If  bulging  outward  can  be 
seen,  the  surgeon  should  make  a  median  anteroposterior  incision  from 
the  scrotum  or  vulva  to  the  coccyx.  The  incision  must  be  exactly  in 
the  middle  line,  so  as  to  divide  the  external  sphincter  at  the  raphe. 
Thus  the  bowel  may  be  entered,  after  which  it  is  carefully  washed  out 
and  the  mucous  membrane  stitched  to  the  skin. 

A  high  closure  of  the  rectum  presents  a  still  more  difficult  problem. 
If  no  bulging  at  the  anus  can  be  seen,  the  surgeon  has  no  knowledge 
as  to  the  location  of  the  rectal  pouch,  and  his  operation,  if  done  as 

^  E.  H.  Small,  in  an  interesting  paper  read  before  the  American  Medical  Associa- 
tion, 1905,  describes  a  difficult  case  of  this  tj^e,  showing  how,  after  aspiration, 
the  bowel  will  itself  gradually  descend  and  unite  with  the  anal  skin. 


92  THE    ABDOMEN 

described  in  the  last  paragraph,  must  be  done  bHndly.  CurHng  and 
Anders  state  that  by  the  perineal  operation  surgeons  have  failed  to  find 
the  bowel  in  30  per  cent,  of  these  cases.  For  this  reason  it  is  good 
practice,  in  the  case  of  such  complete  rectal  occlusion,  to  open  the 
abdomen  above  the  pubes,  to  establish  an  artificial  anus  in  the  groin, 
and  later,  perhaps  after  many  months,  when  the  child  is  well-nourished 
and  vigorous,  to  make  a  secondar}'  operation  by  the  combined  method, — 
working  from  above  and  below, — in  order  to  bring  down  the  rectal 
pouch.  This  is  the  intelligent  and  proper  surgical  method.  Blind 
groping  from  below  is  dangerous;  especially  to  be  condemned  is  blind 
aspiration  from  below,  because  thus  one  is  almost  certain  to  open  the 
peritoneal  cavity  and  is  likely  to  smear  it  with  meconium. 

Rectal  occlusion  combined  with  fistula  into  the  other  organs  pre- 
sents another  problem  difficult  of  treatment.  Fortunately,  the  con- 
dition is  rare.  The  operation  begins  like  that  for  uncomplicated  oc- 
clusion. When  the  bowel  is  low  down,  it  should  be  reached  by  the 
perineal  route.  Then  the  bladder  or  urethra  must  be  separated, — a 
difficult  matter, — and  it  is  well,  as  a  preliminary,  to  pass  a  small  sound 
through  the  urethra  or  bladder  into  the  rectum,  and  so  to  locate  the 
lowest  point  of  the  latter  organ.  Often  the  point  of  the  sound,  when 
it  is  directed  toward  the  anus,  may  be  felt  in  the  anal  cleft.  Deep 
dissection  of  the  perineum  will  then  develop  the  fistula,  which  must 
be  clamped,  cut  off,  and  the  bowel  and  vesical  openings  turned  in  and 
sutured.  If  the  fistula  is  placed  high,  so  as  not  easily  to  be  reached, 
the  abdomen  should  be  opened,  an  artificial  anus  established,  and  later 
a  secondary  operation  done  to  close  the  rectovesical  fistula.  In  all  these 
operations  abundant  provision  for  drainage  must  be  made,  and  every 
pains  must  be  taken  to  prevent  soiling  the  peritoneum  with  meconium 
and  feces. 

At  the  best,  these  operations  show  a  high  mortality,  and  Anders 
publishes  the  following  table : 

Cases.  Mortality. 

Proctoplasty .44  29  per  cent. 

Incision 27  33 

Colostomy 21  52 

Puncture' 4  50    "        " 

INFLAMMATIONS 

Inflammations  about  the  rectum  and  anus  are  manifold,  and  lead 
to  a  great  variety  of  results,  depending  upon  the  origin  of  the  infection. 
They  may  give  rise  to  hemorrhage  or  to  intestinal  obstruction  through 
peritonitis.  Owing  to  the  extremely  septic  condition  of  the  normal 
rectal  mucosa,  these  inflammations  are  frequently  acute  and  sometimes 
fatal.  Septicemia,  pyemia,  general  peritonitis,  and  gangrene  may 
result,  and  must  be  treated  appropriately  when  they  are  discerned. 
Such  alarming  conditions  call  for  extensive  drainage  and  excision  of  the 
necrotic  portions.  Foreign  bodies,  such  as  fish-bones,  safety-pins,  and 
gall-stones,  may  lodge  in  the  rectum,  and  great  fecal  masses  may  become 
inspissated  and  plug  the  outlet.     Many  years  ago  I  saw,  at  the  ]\Iass- 


INFLAMMATIONS  93 

achusetts  General  Hospital,  a  ciuious  case  in  the  service  of  M.  H. 
Richardson.  The  patient,  a  man  with  perverted  instincts,  had  intro- 
duced through  the  aims  a  large  catsup-bottle,  of  c[uart  size,  neck  first, 
until  it  slipped  from  his  fingers  and  j^assed  into  the  bowel.  Such 
large  bodies  can  be  secured  only  by  splitting  the  sphincter  backward 
to  the  coccyx  so  as  to  allow  of  their  free  exit.  Small  bodies,  like  fish- 
bones, can  be  seen  through  the  proctoscope,  and  may  be  secured  with 
the  fingers  or  forceps.  Fecal  masses  may  be  dissolved  and  washed  out 
with  lime-water  enemata,  or  may  be  broken  up  and  removed  piecemeal 
with  a  spoon  or  the  finger. 

I  have  seen  serious  damage  to  the  rectum  inflicted  by  the  patient 
himself  roughly  introducmg  the  hard  nozzle  of  a  Davidson  syringe, 
which  lacerated  the  mucosa  and  gave  rise  to  a  wdde-reaching  periproctitis; 
the  resulting  inflammation  was  so  extensive  that  the  mass  encroached 
upon  the  rectum,  and  for  some  time  was  mistaken  for  a  malignant 
growth. 

Inflammations  about  the  rectum  and  anus  arise  commonly  from 
external  causes,  or  from  ulcerations  of  the  mucosa  extending  to  and 
involving  the  surrounding  tissues.  Pruritus  ani  is  one  of  the  commonest 
and  most  distressing  of  conditions.  It  is  a  symptom,  not  a  disease.  It 
may  be  due  to  a  variety  of  causes,  from  syphilis  or  gonorrhea  to  a  simple 
eczema,  to  pin-worms,  or  to  filthy  habits. 

Treatment  must  be  directed  to  removing  the  underlying  cause,  and 
especially  the  frequent  constipation,  while  for  the  local  conditions 
the  surgeon  must  prescribe  careful  soap-and-water  bathing  several 
times  daily,  and  the  application  of  an  oxid  of  zinc  ointment,  or  a  wash 
composed  of  phenol,  1  part;  alcohol,  3  parts;  chloral  hydrate,  10  parts; 
water,  86  parts.  J.  R.  Pennington  ^  reports  excellent  results  from 
the  x-ra.\  treatment  of  pruritus,  and  his  experience  corresponds  with 
my  own. 

Simple  proctitis  and  ulcers  of  the  rectxim  may  be  due  to  mechanical 
irritation,  such  as  the  pressure  of  a  tied-down  uterus,  to  the  use  of 
strong  laxatives,  exposure  to  cold,  foreign  bodies,  fecal  impactions, 
traumatisms  from  hard  sj'ringe  nozzles,  and  to  hemorrhoids,  rectal 
prolapse,  on  anal  fissure.  The  course  of  the  inflanmiation  may  be 
acute  or  chronic,  and  the  actual  condition  invariably  must  be  ascer- 
tained by  the  use  of  the  proctoscope  and  by  digital  examination.  The 
symptoms  are  fever,  tenesmus  with  straining,  fluctuating  pains,  and 
bloody  or  mucous  stools.  The  treatment  consists  in  removing  the  cause, 
if  possible,  rest  in  bed,  a  carefully  regulated  diet, — mainly  of  broth. — 
and  mild  daily  irrigations  of  normal  saline  solutions,  or  2  per  cent, 
solution  of  argyrol.  Sometimes  ulcers  may  be  treated  by  touching 
them  with  caustic  (silver  nitrate)  or  the  actual  cautery,  and,  above  all 
things,  it  is  essential  that  a  tight  sphincter  should  be  thoroughly  dilated; 
indeed,  a  great  many  of  these  local  infections  are  due  to  chronic  spasm 
of  the  sphincter. 

Gonorrheal  inflammation  of  the  rectum  is  not  uncommon, 
1  N.  Y.  Med.  Jour.,  Februan'  20,  1904. 


94  THE   ABDOMEN 

especiall}'  in  women,  in  whom  the  infection  occurs  by  direct  extension 
from  the  vulva.  The  tn-aiment  is  similar  to  that  described  in  the 
previous  paragraph. 

Syphilitic  affections  of  the  anus  and  rectum  must  be  treated  on 
general  principles,  with  to})ical  applications  of  iodoform,  by  irrigation, 
and  by  the  internal  administration  of  mercury  and  the  iodids,  accord- 
ing to  the  progress  of  the  disease. 

Tuberculosis  of  the  anus  and  rectum  shows  itself  in  ulcerations, 
abscesses,  and  fistula^.  Ulcerations  must  be  treated  locally,  and 
abscesses  must  be  opened,  but  far  more  important  is  hygienic  treat- 
ment directed  to  the  general  tuberculous  condition.  This  treatment 
embraces  a  constant  life  in  the  open  air,  whether  in  city  or  country, 
and  such  tonics  as  iron,  malt,  and  cod-liver  oil.  An  out-of-doors  life 
often  suffices  to  relieve,  or  to  effect  a  cure,  in  these  cases. 

FISSURE   OF   THE  ANUS 

Fissure  of  the  anus,  improperly  so  called,  is  a  trifling  but  very 
distressing  affection.     Properly,  anal  fissure  is  a  small  ulcer  at  the  muco- 


Fig.  35. — Fissure  of  anus. 

cutaneous  margin.  It  may  be  due,  among  other  causes,  to  fecal  irrita- 
tion, piles,  or  scratching.  With  the  patient  in  the  lithotomy  position, 
the  anal  folds  may  be  stretched  apart  and  the  ulcer  revealed.  Treat- 
ment is  either  palliative  or  radical,  and  the  radical  treatment  generally 


ISCHIORECTAL   ABSCESS  95 

is  the  better.  Palliative  treatment  involves  constant  visits  to  the  sur- 
geon, who  applies  cleansing  applications,  drying  powders,  and  caus- 
tics, with  directions  for  a  limited  diet  and  careful  regulation  of  the 
bowels.  By  such  means  the  ulcer  may  heal  after  weeks  or  months, 
but  the  activity  of  the  sphincter  and  the  frequent  passage  of  feces 
over  the  ulcer  render  its  healing  through  these  measures  a  tedious 
process.  The  radical  treatment — which  is  usually  to  be  recommended 
— consists  in  a  slight  operation,  quickly  recovered  from :  the  bowels  are 
thoroughly  evacuated,  the  patient  etherized,  and  the  sphincter  para- 
lyzed by  stretching.  A  simple  index  of  proper  stretching  is  the  passing 
of  the  surgeon's  four  fingers,  up  to  the  metacarpal  joints,  into  the 
rectum,  until  they  slide  easily  in  and  out.  The  sphincter  remains 
paralyzed  for  a  few  days,  and  the  quiescent  ulcer  has  a  chance  to  heal, 
while  fecal  movements  are  prevented  by  the  use  of  a  broth  diet.  On  the 
fifth  clay  the  bowels  are  moved  by  cascara,  oil,  and  an  oil  enema.  After 
this  the  patient  may  resume  his  regular  habits  as  to  diet,  and  may  go 
about  his  business. 

ISCHIORECTAL  ABSCESS 

Ischiorectal  abscess  is  a  general  term  applied  to  abscesses  in  the  peri- 
proctal  connective  tissue.  A  glance  at  the  accompanying  figure  (Fig. 
36)  shows  how  numerous  may  be  the  sites  and  directions  of  burrowing 
of  such  abscesses.  Ischiorectal  abscess  is  common,  and  examples  of 
it  may  be  found  frequently  in  every  surgical  ward.  It  occurs  in  persons 
of  all  ages  and  in  all  degrees  of  health.  It  may  be  acute  or  chronic; 
it  may  be  localized  or  diffused.  The  commonest  form  of  abscess  in  this 
region  starts  in  the  neighborhood  of  the  sphincter  ani,  and  is  localized 
in  the  fat  tissues  about  the  anus,  outside  of  the  deep  pelvic  fascia. 
Again,  it  may  extend  beyond  the  fascia  and  involve  the  soft  parts, 
between  the  ischium  and  the  levator  ani  muscle,  or  it  may  pass  beneath 
the  internal  sphincter,  burrow  up  indefinitely  along  the  rectum  and 
invade  the  peritoneum.  The  extent  and  location  of  these  abscesses 
are  in  the  order  I  have  named,  but  the  superficial  acute  abscess  is  far 
the  most  common. 

These  periproctal  abscesses  are  due  usually  to  some  irritation  within 
the  rectum  or  anus,  such  as  abrasion  by  hard  fecal  masses,  small  ulcers, 
ulcerating  piles,  or  wounds  by  foreign  bodies.  Sometimes  a  fissure  is 
the  source.  Frequently  the  patient  will  tell  you  that  he  noticed  his 
first  pain  after  a  difficult  movement  of  the  bowels.  The  pain  is  sharp 
and  throbbing.  Sitting  down  is  very  distressing.  The  sufferer  must 
stand  or  recline.  Movements  of  the  bowels  are  agonizing  often.  The 
patient  is  feverish,  distressed,  loses  his  appetite,  and  will  tell  you  that 
he  is  a  very  sick  man.  The  severity  of  the  symptoms  seems  out  of  all 
proportion  to  the  apparent  extent  of  the  lesion,  but  the  severity  of  the 
symptoms  is  no  trifle,  because  septic  absorption  from  this  lesion  is  rapid 
and  continuous. 

Diagnosis. — The  surgeon  cannot  thoroughly  examine  the  patient 
without  an  anesthetic,  but  generally,  in  spite  of  the  sufferer's  extreme 


96 


THE   ABDOMEN 


sensitiveness,  the  surgeon  may  pass  his  forefinger  within  the  sphincter, 
where  he  will  detect  a  smooth,  rounded  induration,  which  may  be 
grasped  between  the  thumb  and  finger,  and  feels  like  a  thickened 
sphincter.  Sometimes  there  is  bleeding  from  distended  and  eroded 
hemorrhoids.  In  some  cases  the  sui"geon  may  be  unable  to  distinguish 
between  a  mass  of  hemorrhoids  and  a  beginning  ischiorectal  abscess; 
indeed,  the  two  may  l)e  associated;  but  the  patient's  account  of  throb- 
bing, boring  pain  and  extreme  distress  on  sitting  down,  with  fever  and 
rapid  pulse,  confirms  the  diagnosis  of  abscess. 


Fig.  36. — Ischiorectal  abscess.     Dotted  lines  indicate  burrowing  fistulae. 

More  deeply  seated  abscesses  are  characterized  by  an  exaggeration 
of  the  symptoms  I  have  described.  The  constitutional  disturbance 
is  graver.  Pulse  and  temperature  may  run  high,  and  the  patient's 
condition  may  be  alarming.  Generall}',  obstipation  is  complete,  and 
there  is  a  high  leukocytosis.  In  advanced  cases  there  may  be  present 
the  signs  of  a  local  or  general  peritonitis.  Examination  of  these  cases 
may  be  difficult,  but  a  glance  at  the  buttocks  usually  is  enough  to 
convince  the  surgeon  that  a  serious  inflammation  is  ])rescnt.  In  acute 
cases  one  sees  a  deep  purplish  injection  of  the  skin,  with  fullness  about 
the  anus  and  edema  of  the  parts.  The  finger  introduced  into  the  rectum 
lights  upon  the  more  or  less  elastic  or  doughy,  constricted  canal. 


FISTULA    IN   ANO  97 

Tlie  treatment  of  all  these  cases  of  acute  abscess  is  operative,  for 
palliation  sekloni  docs  good  even  to  the  mildest  cases.  Writers  will 
tell  you  that  cold  ap])lications,  cold  sitz-baths,  warm  saline  irrigation, 
and  sundiy  lnllch-^'aunted  remedies  may  abort  the  disease.  Do  not 
be  misled.  Harely  with  a  superficial  abscess  at  the  outset  you  may 
succeed  by  applications  in  checking  its  progress,  but  do  not  procrastinate 
more  than  twenty-four  hours. 

The  operation  for  all  forms  of  periproctal  abscess  is  free  incision 
and  drainage.  Open  by  a  cut  parallel  to  the  fibers  of  the  external 
sphincter — either  through  it  or  outside  of  it.  Usually  you  may  avoid 
opening  the  rectum.  Scoop  out  thoroughly  all  pus  and  sloughs.  Ir- 
rigate and  pack  lightly  with  iodoform  gauze.  Generally,  reaction 
begins  at  once,  and  in  a  few  days  comparative  health  is  restored;  but 
the  patient  must  be  kept  in  bed  as  long  as  the  wound  requires  deep 
packing,  and  he  must  appreciate,  from  the  outset,  that  the  convales- 
cence will  be  slow.  As  usual,  when  the  rectum  is  operated  upon,  the 
bowels  must  be  kept  quiet  by  the  use  of  a  liquid  diet  without  milk  for 
a  few  days,  and  after  regular  movements  are  established  the  wound 
should  carefully  be  kept  cleaned  by  irrigation  after  every  defecation. 

Chronic  abscess  about  the  rectum  and  anus  is  not  commonly  a  sequel 
of  acute  abscess,  but  is  due  most  often  to  tuberculosis,  and  it  starts 
either  inside  the  rectum  or  about  the  anus.  Such  chronic  abscesses 
develop  slowly  and  with  little  discomfort  to  the  patient.  He  discovers 
them  finally  by  the  sense  of  touch  or  by  observing  some  slight  obstruc- 
tion to  defecation,  with  possibly  pus  or  blood  in  the  stools.  These 
abscesses  must  be  opened,  drained  thoroughly,  and  made  to  heal  from 
the  bottom  b}^  daily  packing  with  sterile  gauze  or  iodoform  gauze. 
The  course  is  very  slow  and  is  dependent  upon  the  patient's  general 
condition,  which  must  be  supervised,  as  I  stated  in  discussing  tuber- 
culosis of  the  rectum. 

FISTULA  IN  ANO 

Fistula  in  ano  is  a  frequent  result  of  inflammation  about  the  rectum, 
and  is  a  direct  outcome  of  ischiorectal  abscess.  Such  a  fistula  represents 
the  track  or  site  of  an  abscess  incomplete^  healed,  and  not  treated  by 
thorough  drainage  from  the  bottom.  It  is  a  common  lesion  and  is  seen 
more  frequently  in  men  than  in  women.  From  my  description  of 
ischiorectal  abscess  the  reader  will  conclude  correctly  that  the  fistula 
may  or  may  not  be  tuberculous.  TMien  tuberculous,  it  is  chronic  and 
obstinate,  and  may  not  heal  under  the  best  of  care  even.  We  recognize 
three  forms  of  fistula  in  ano :  (1)  Blind  internal  fistula,  which  represents 
an  abscess  that  has  opened  into  the  rectum;  (2)  blind  external  fistula, 
w^hich  represents  an  abscess  that  has  opened  externally;  and  (3)  com- 
plete fistula,  representing  an  abscess  which  has  opened  internalh'  and 
externally.  The  internal  opening  may  be  above  or  below  the  external 
sphincter.  These  fistulse  may  be  numerous  and  complicated,  and 
may  have  many  tracks  burrowing  in  all  directions  into  the  buttocks. 

The  sjrmptoms  of  fistula  are  annoying,  but  are  not  often  painful. 
7 


98 


THE    AUDOMEN 


The  blind  internal  fistula  may  become  a  receptacle  for  feces  and  so  one 
may  see  a  secondary  abscess  and  extension  of  the  process.  The  blind 
external  fistula  a])pears  to  the  patient  as  a  trifling  running  sore  generally, 
which  may  itch  and  throb  occasionally.  The  complete  fistula  forms 
a  false  channel  for  the  passage  of  feces  and  fiatus,  and  is  the  most  annoy- 
ing form  of  this  disease. 

The  diagnosis  must  be  made  by  careful  inspection  of  the  parts  and 
by  probing  to  ascertain  the  situation  and  extent  of  the  fistula. 

The  only  rational  treatment  is  by  operation,  though  sundry  prac- 
titioners still  attempt  a  cure  by  the  ancient  methods  of  irritant  injec- 
tions and  by  setons.  Before  the  radical  operation  the  patient  must  have 
his  bowels  thoroughly  cleared  out  and  the  parts  shaved  and  cleansed 


Fig.  37. — Form-s  of  fistulse  (schematic). 

with  soap  and  water.  He  must  be  anesthetized,  but  a  preliminary 
stretching  of  the  sphincter,  as  sometimes  is  proposed,  is  not  necessary. 
The  usual  operation  consists  in  passing  a  probe  or  director  into  the 
depths  of  the  fistula,  or  through  it,  if  it  is  complete,  and  a  thorough 
laying  open  of  the  tract,  followed  by  cureting  or  cauterizing  and  packing 
with  iodoform  gauze.  It  is  sometimes  difficult  to  discover  the  opening 
of  a  blind  internal  fistula.  One  may  have  to  dilate  the  sphincter  with 
the  fingers  or  pass  the  proctoscope.  Insert  a  bent  probe  into  the  fi.stulous 
opening,  and  pass  it  to  the  bottom  of  the  fistula;  then  lay  open  the 
tract  with  a  knife.  A  majority  of  all  fistulse  leave  the  external  sphinc- 
ter uninvolved,  but  if  this  muscle  is  penetrated  or  involved  by  the 
fistula,  it  must  be  cut  across.     The  cut  sphincter  recovers  its  normal 


HEMORRHOIDS 


99 


function  (almost  always),  especially  if  it  be  cleanly  divided  in  one  place 
only,  and  if  that  place  be  at  the  raphe. 

In  operating  upon  fistulas  which  do  not  penetrate  or  involve  the 
rectal  canal  the  surgeon  may  sometimes  practise  a  careful  dissecting 
out  of  the  tract.  Pass  a  stout  probe  or  grooved  director  through  the 
fistula,  and  dissect  around  it,  cutting  out  the  probe  with  its  sheath  of 
fistula  exactly  as  though  it  were  a  vermiform  tumor.  This  procedure 
leaves  behind  a  clean,  fresh,  superficial  wound,  which  may  be  sewed  up 
by  encircling  stitches,  carefully  inserted  so  as  to  take  up  and  obliterate 
the  gap.  I-'rcquently  one  succeeds  in  securing  a  primary  union  by  this 
method,  but  -when  emplojdng  it,  one  must  pay  the  closest  attention  to 
aseptic  technic.  After  all  operations  upon  fistulse  I  recommend  keep- 
ing the  bowels  quiet  for  five  days  at  least,  or  a  week  if  the  patient  can 


Fig.  38. — Operation  for  fistula  in  ano. 

be  made  comfortable.  The  outside  dressing  after  these  operations,  as 
after  all  operations  upon  the  anus  and  rectum,  is  a  rather  scant  pad  of 
gauze  and  cotton  held  in  place  by  a  T-bandage. 


HEMORRHOIDS 

Hemorrhoids  are  common  to  all  mankind.^  First  and  last,  few 
persons  escape  them.  Hemorrhoids  are  usually  regarded  as  distended, 
tortuous  veins — varices  of  the  rectum.  Reinbach  thinks  the  essential 
part  of  the  process  to  be  a  new  formation  of  capillary  vessels.  There- 
fore he  speaks  of  hemorrhoids  as  angiomata.  Gunkel  agrees  with  him, 
but  has  found  the  veins  to  be  varicose  in  a  few  cases  of  pregnancy  and 
pelvic  tumor. 

^  The  common  term  piles  is  from  the  Latin  pila,  a  ball  or  rounded  mass. 


100  THE    ATU)OMEN 

We  (listiiiiiuish  tliicc  ^•;u■i(■ti('s  of  hcnioi-i-hoids:  Internal  hemorrhoids, 
found  within  the  external  sphincter,  and  developed  in  the  superior 
hemorrhoidal  plexus  of  veins;  externa}  hemorrhoids,  developed  about 
the  anus,  in  the  branches  of  the  inferior  hemorrhoidal  plexus,  the  blood 
from  which  passes  into  the  pubic  veins;  and  wixed  hemorrhoids,  which 
are  a  combination  of  the  other  two. 

Internal  hemorrhoids  are  the  most  difficult  to  determine;  they 
vary  much  in  size,  according  to  the  nature  and  caliber  of  vessels  in- 
volved, and  they  may  or  may  not  bleed  easily.  They  extend  from  just 
above  the  anal  margin  upward  for  an  inch  or  two.  Arteries  are  not 
involved.  Piles  are  due  to  any  cause  which  induces  venous  congestion 
of  the  rectum — pregnancy,  tumors,  habitual  constipation,  portal  ob- 
struction, certain  heart  and  pulmonary  diseases,  sedentary  occuj^ation, 
and  stricture  of  the  urethra.  Probably  constipation  is  the  most  common 
cause.  Conversely,  piles  are  a  catise  of  constipation.  Constantly  one 
sees  neurotic  persons,  especially  neurasthenic  women,  who  suffer  from 
constipation  and  have  a  consequent  development  of  piles.  Remove 
the  piles  and  you  will  cure  the  constipation,  which  in  turn  has  been 
aggravated  by  the  piles.  The  patient  with  piles  dreads  the  act  of  defeca- 
tion, and  so  a  vicious  circle  is  established. 

The  most  common  symptom  of  internal  hemorrhoids  is  bleeding — 
usually  a  few  drops,  a  mere  streaking — occasionally  a  considerable 
gush  of  bright  blood.  Observe  that  the  blood  from  hemorrhoids  is 
bright  and  fresh  in  contrast  with  the  tarry,  partly  digested  blood  which 
comes  from  high  up  in  the  intestines.  Sometimes  piles  cause  a  sense 
of  weight,  oppression,  and  aching.  Finall}"  they  protrude  w^hen  the 
bowels  move,  and  must  be  replaced  if  subseciuent  pain  is  to  be  avoided. 
Truly  painful  piles  are  those  which  protrude,  ai'e  caught  down  by  the 
sphincter,  and  become  engorgetl  and  strangulated.  Such  strangulated 
piles  may  swell  to  a  considerable  size^as  large  as  a  child's  fist  even, 
and,  if  unrelieved,  become  necrotic,  gangrenous,  and  may  slough  off. 

The  treatment  of  internal  piles  varies  according  to  the  gravity 
of  the  case.  Small  masses,  which  bleed  seldom  and  do  not  protrude, 
may  be  kept  in  subjection  by  palliative  measures,  such  as  a  restricted 
diet  and  the  avoidance  of  alcohol,  highly  spiced  foods,  and  slothful 
habits.  Prescribe  regular  exercise,  a  course  of  Carlsbad  salts,  and 
nightly  doses  of  cascara  sagrada.  After  each  movement  of  the  bowels, 
and  night  and  morning,  direct  the  patient  to  apply  a  cold  sponge  to  the 
anus  for  five  minutes.  The  cold  douche,  directed  against  the  parts, 
is  still  better.  Slight  bleeding  may  be  relieved  and  controlled  by 
astringent  injections,  and  of  these,  an  excellent  remedy  is  fluidextract 
of  hamamelis,  of  which  one-half  ounce  is  injected  morning  and  night 
into  the  rectum,  and  retained.  Sundry  ointments  and  suppositories  are 
recommended,  one  of  the  best  of  which  is  Allingham's  ointment,  which 
should  be  rubbed  in  thoroughly  after  the  use  of  the  cold  water.^  G. 
W.  Gay,  of  Boston,  a  surgeon  of  the  widest  experience,  writes  to  me: 

^  Allingham's  ointment :  Extract  of  conium  and  extract  of  hj^oscyamus,  of 
each,  2  drams;   extract  of  belladonna,  1  dram;   petrolatum,  1  ounce. 


HEMORRHOIDS 


101 


"Internal  piles  may  generally  be  nuicli  relieved,  not  cured,  by  injecting 
one  or  two  drops  of  the  following  mixture:  Phenol  (95  per  cent.),  1  part; 
glycerin  and  water,  each,  5  parts.  Two  piles  may  be  injected  at  once. 
No  repetition  for  at  least  one  week.  The  patient  has  no  pain  to  speak 
of,  keeps  at  his  work,  and  nine  times  out  of  ten  gets  so  much  relief  that 
he  refuses  more  radical  treatment."  In  a  published  article  he  sums 
up  his  treatment  as  follows : 

"1.  Inject   only   internal   piles.     2.  The   solution   of   carbolic    acid 
should  not  exceed  10  per  cent.     3.  Do  not  repeat  the  operation  under 


Fig.  39. — Clamp  and  cautery  applied  in  operation  for  hemorrhoids. 

a  week.  4.  Inject  only  one  or  two  minims  into  each,  tumor.  5.  Inject 
not  more  than  two  piles  at  any  one  time.  6.  Promise  relief  only,  and 
not  a  radical  or  a  permanent  cure."  If  the  piles  protrude  and  cannot 
be  reduced,  the  patient  should  be, put  to  bed  and  an  operation  under- 
taken; meantime,  if  you  choose,  relief,  or  reduction  even,  may  be 
brought  about  by  the  sedative  action  of  opium  and  hot  poultices. 

There  are  two  operations  especially  to  be  recommended  for  extensive 
hemorrhoids — their  removal  by  clamp  and  cautery  and  their  resection 
— commonly  known  as  Whitehead's  operation. 

Clamp  and  Cautery. — The  bowels  should  be  thoroughly  evacuated 


102  THE   ABDOMEN 

by  castor  oil  and  cnemata,  and  the  jjaticnt  .should  be  kept  on  a  liquid 
diet  for  twenty-four  hours  before  the  operation,  ^^'hen  operating,  have 
the  patient  on  a  table  in  a  strong  light  and  in  the  lithotomy  position. 
Thoroughly  clean  and  shave  the  external  parts,  and  stretch  the  sphincter 
with  the  fingers.  This  evacuates  any  remnants  of  the  enema  and 
allows  the  piles  to  drop  down  within  easy  reach.  When  operating  by 
clamp  and  cautery,  it  is  not  necessary  to  remove  all  the  masses, — three 
are  enough, — as  too  thorough  removal  results  sometimes  in  stricture  of 
the  rectum.  Grasp  the  bunch  of  piles  with  the  forceps  and  squeeze  it 
tight  in  a  strong  clamp,  taking  great  pains  not  to  include  skin,  and  see 
to  it  that  the  clamp  is  placed  parallel  to  the  course  of  the  rectum  and 
not  across  it.  Crush  the  piles  thoroughly.  Some  surgeons  regard  this 
as  sufficient  and  end  the  operation  here.  I  prefer  to  employ  the  cautery 
also.  With  the  crushed  hemorrhoid  protruding  from  the  clamp  cut 
away  the  redundant  tissue  and  sear  thoroughly  the  stump  outside 
of  the  clamp.  Caution:  The  clamp  may  become  very  hot  and  bum  or 
blister  the  buttocks;  therefore,  protect  the  skin  carefully  with  an 
asbestos  shield  or  wet  sponges.  Having  removed  two  or  three  bunches 
of  piles  and  observed  that  hemorrhage  is  checked,  allow  the  parts  to  sink 
back.  Insert  a  I  grain  morphin  suppository,  or,  better  still,  dust  the 
lacerated  parts  within  the  sphincter  thorough^  with  sodium  bicarbon- 
ate.    This  usually  suffices  to  relieve  pain. 

Whitehead's  operation,  so  called,  is  practised  and  advised  by  many 
experienced  surgeons.  It  is  applicable  to  low-lying  hemorrhoids  only. 
If  employed  high  in  the  rectum,  it  may  give  rise  to  stricture.  The 
operation  consists  in  stretching  the  sphincter,  turning  out  the  hemor- 
rhoids, excising  them  with  a  knife,  and  sewing  the  severed  mucous 
membrane  to  the  skin. 

External  hemorrhoids  are  classified  by  Tuttle  as  thrombotic, 
varicose,  inflammatory,  and  connective-tissue  hemorrhoids.  The  tenns 
are  self-explanatory  and  indicate  various  stages  of  the  same  process. 
These  hemorrhoids  are  multiple  generally.  If  the  veins  are  filled  with 
clots,  they  may  be  opened  with  the  knife  and  washed  out.  If  they  are 
varicose,  they  may  be  treated  by  either  of  the  methods  already  de- 
scribed— clamp  and  cautery  or  excision;  and  the  same  statement 
applies  to  inflammatory  hemorrhoids.  The  symptoms  of  all  these  con- 
ditions are  pain  and  itching,  with  occasional  slight  hemorrhage.  Con- 
nective-tissue hemorrhoids  or  skin  tabs  are  due  to  hypertrophy  of  the 
mucocutaneous  tissue  at  the  margin  of  the  anus.  They  are  to  be 
treated  by  excision  with  the  knife  or  scissors. 

PROLAPSE  OF  THE  ANUS  AND  RECTUM 

Prolapse  of  the  anus  and  rectum  is  closely  allied  to  hemorrhoids, 
which  are  a  frequent  cause  of  prolapse,  as  well  as  a  complication  of 
that  condition.  B}-  prolapse  of  the  anus  we  mean  a  protnision  of  the 
mucous  membrane  only.  By  prolapse  of  the  rectum  we  mean  a  pro- 
trusion of  the  whole  thickness  of  the  gut.     The  causes  of  these  protru- 


PROLAPSE  OF  THE  ANUS  AND  RECTUM 


103 


sions  are  numerous,  and  includes,  Ijcsides  heniorrhoid.s,  tumors,  long- 
standing diarrhea  and  constipation,  procttitis,  congenital  rectal  stenosis, 
\\'orms,  phimosis,  stone  in  the  bladder,  whooping-cough,  and  sundry 
exhausting  constitutional  disturbances  which  weaken  the  rectal  sup- 
ports, rendering  them  unable  to  withstand  straining  at  stool.  Prolapse 
is  not  uncommon  in  children,  and  is  seen  in  persons  of  all  ages,  especially 
in  women  ^^•ho  have  suffered  from  extensive  lacerations  in  childbed. 

The  sy7nptoms  are  protrusion  of  the  gut  or  its  lining,  mucous  or 
bloody  discharges,  and  pain.  If  the  prolapsed  bowel  is  not  reduced,  it 
may  become  engorged  up  to  the  point  of  strangulation  and  gangrene, 
but  the  last  condition  is  uncommon.  The  rule  is,  chronic  prolapse 
easily  reduced. 


Fig.  40. — Prolapse  of  the  rectum. 

The  treatment  is  either  palliative  or  operative.  Palliative  measures 
include  as  most  important:  defecation  in  the  recumbent  position,  a 
carefully  regulated  diet,  the  use  of  laxatives  and  enemata,  and  daily 
flushing  of  the  bowel  with  cool  water.  Moreover,  the  primary  cause 
must  be  removed — such  causes  as  phimosis  and  stone  in  the  bladder. 
A  rectal  support  by  truss  or  napkin  constantly  must  be  worn.  By  such 
means  many  cases  of  prolapse  in  children  may  be  cured. 

Operative  treatment  varies  according  to  the  extent  and  chronicity 
of  the  disease.  If  the  mucosa  alone  protrudes  and  the  condition  is 
recent,  longitudinal  searing  with  the  Paquelin  cautery  may  suffice. 
An  effective  method  of  operating  is  to  take  a  wedge-shaped  excision, 


104  THE    ABDOMEN 

nuulo  i)Osteriorly,  its  base  at  the  anal  margin.  The  wound  is  closed 
at  once  with  deej)  catgut  sutures,  combined  with  a  superficial  sutui'ing 
of  the  mucosa  and  of  the  skin.  When  the  prolapse  is  of  long  standing, 
especially  when  it  is  complicated  with  ulceration,  chronic  inflammation, 
or  new-growths,  the  })rotruding  portion  must  be  amputated  in  the 
following  manner:  Tlie  i)rolai)se  is  grasped  with  clamp  forceps  above 
the  tliseased  area,  carefully  cleansed  and  disinfected,  and  suri'ounded 
with  gauze.  A  small  incision  is  made  into  the  mucosa,  and  then  into 
the  wall  of  the  rectum,  until  the  fold  is  reached  which  separates  the 
two  walls  of  the  prolapse.  When  this  space  has  been  opened,  a  suture 
is  introduced,  and  as  the  surgeon  proceeds  with  the  dissection  above 
the  forceps,  interrupted  sutures  are  applied  at  once  to  shut  off  the 
peritoneal  cavity.  When  the  separation  is  completed,  the  final  step 
consists  in  uniting  with  a  continuous  suture  the  contiguous  lines  of 
mucosa.  Rectopexy  and  dgmoidopexy  are  satisfactory  operations  and 
are  done  as  follows:  the  abdomen  is  opened,  and  the  prolapsed  gut  is 
drawn  up  and  fixed  along  a  considerable  length  by  two  rows  of  con- 
tinuous Lembert  stitches  to  the  peritoneum  of  the  iliac  fossa. 

STRICTURE  OF  THE  RECTUM 

Stricture  of  the  rectum  may  be  congenital  or  acquired,  and  the  ac- 
quired forms  are  due  to  new-growths  and  inflammatory  processes. 
The  characteristics  of  congenital  forms  and  of  tumor  or  neoplastic 
forms  are  obvious.  Inflammatory  stricture  arises  from  extensive  damage 
to  the  mucosa,  resulting  in  scar-tissue  formation  and  contraction. 

The  symptoms  of  inflammation  of  the  rectum  and  their  appropriate 
treatment  have  been  described.  The  symptoms  of  organic  obstruction, 
however,  are  of  gradual  onset.  W^ith  organic  obstruction  there  are 
increasing  constipation,  pain,  and  streaks  of  blood  in  the  stools.  Later, 
lifjuid  movements  only  are  passed.  If  the  stricture  is  low  down,  but 
of  caliber  sufficient  to  admit  formed  feces,  the  masses  may  pass  thin 
or  ribbon-shaped.  Such  deformed  masses  are  not  seen  when  the 
stricture  is  above  the  ampulla.  The  motions  are  then  normal  in  appear- 
ance. Sometimes,  with  the  accumulation  of  fecal  masses,  there  may 
result  intestinal  obstruction,  more  or  less  complete,  with  such  con- 
stitutional changes  as  loss  of  weight,  aneaiia,  indigestion,  stercoremia, 
and  sundry  nervous  phenomena. 

The  diagnosis  must  be  made  by  digital  examination  or  by  the  use 
of  the  proctoscope. 

The  treatment  for  rectal  stricture  is  various,  depending  on  the  cause 
of  the  obstruction  and  its  location.  Acute  inflammation  must  be 
subdued,  careful  dieting  and  rest  in  bed  must  be  prescribed,  and  if  an 
active  syphilis  or  tuberculosis  be  present,  it  must  be  treated;  but  be  it 
observed  that  old  cicatrices,  due  to  healed  syphilitic  ulcers,  are  not 
affected  by  potassium  iodid.  The  caliber  of  the  gut  must  be  maintained 
by  the  careful  use  of  bougies.  Lothrop  describes  the  operative  treatment 
of  rectal  stricture  as  dilatation,  proctotomy,  excision,  enter o-anastomosis, 


TUMORS   OF   THE   ANUS   AND    RECTUM  105 

colostomy,  and  pnxiopldsh/.  (!raclual  dHaldtion  is  safe  and  generally 
satisfactory.  Kapid  divulsion  is  dangerous.  Proctotomy  consi.sts  in 
incising  the  stricture  cither  from  without  or  from  within — when  from 
without,  the  disease  is  reached  through  the  vagina  or  through  the  coccyx 
and  sacrum.  Dilatation  is  necessar}-  as  part  of  the  after-treatment, 
and  the  method  is  unsatisfactory,  except  as  a  palliative  measure.  Ex- 
cision of  the  stricture  is  performed  in  a  fashion  similar  to  excision  of 
other  lesions  of  the  rectum,  and  will  be  described  later  in  this  chapter. 
Entero-anastomosis  is  applicable  only  in  case  of  high  stricture  of  the 
rectum,  when  a  loop  of  the  sigmoid  flexure  ma}'  be  brought  doT\Ti  and 
joined  to  the  rectum  below  the  stricture.  Colostomy  is  employed  in  the 
case  of  inoperable  malignant  disease,  or  in  the  case  of  benign  stricture, 
when  immediate  relief  is  necessary  to  save  life.  Proctoplasty  is  a  useful 
measure,  and  is  applicable  often  to  the  strictures  found  in  the  last  3 
inches  of  the  rectum.  Lothrop  describes  an  interesting  method  of 
proctoplasty-.^  He  reports  the  case  of  a  woman  who  was  afflicted  with 
a  close  stricture  of  the  rectum  2  inches  above  the  anal  openiiig.  The 
operator  approached  the  stricture  from  the  front,  splitting  the  septum 
between  the  rectum  and  vagina  by  the  so-called  Tait  method.  A  Xo. 
18  French  sound  was  then  passed  through  the  anus  and  stricture,  and 
its  tip  was  made  to  impinge  upon  the  anterior  wall  of  the  rectum,  pressing 
it  up  into  the  wound.  Upon  the  sound,  as  a  guide,  the  rectum  was 
opened,  longitudinally,  a  sufficient  distance,  and  was  held  open  by 
retractors.  This  cut  split  the  stricture.  The  posterior  wall  of  the 
rectum  was  then  incised  in  a  similar  fashion,  the  knife  being  introduced 
through  the  anterior  incision.  The  cuts  anterior  and  posterior  were 
then  closed  by  approximating  their  upper  to  their  lower  ends,  following 
the  well-known  Heineke-]\Iikulicz  method  of  pyloroplasty.  This  opera- 
tion resulted  in  securing  a  competent  lumen  for  the  rectum,  which  at 
the  time  of  writing  had  performed  its  function  satisfactorily  for  more 
than  a  j'ear.  In  the  case  of  a  man  the  same  operation  may  be  done  by 
approaching  the  rectum  from  behind,  with  or  without  resection  of  the 
coccyx  and  sacrum.  After  an  operation  for  widening  the  caHber  of  the 
rectum  it  is  generally  necessary  to  follow  up  the  treatment  for  a  long 
time,  even  for  life,  by  occasionally  dilating  with  bougies. 

TUMORS  OF  THE  ANUS  AND  RECTUM 

Tumors,  and  malignant  tumors  especially,  offer  the  most  perplexing 
problems  of  the  various  diseases  of  the  rectum  and  anus.  As  with 
tumors  elsewhere,  a  cure  depends  on  extirpation;  but  extii'pation  of 
the  lower  bowel  is  one  of  the  most  chfRcult  of  surgical  procedures, 
because  complete  eradication  means  a  long  and  trjang  dissection,  be- 
cause the  restoration  of  a  complete  anal  outlet  rarel}-  is  possible,  and 
because  asepsis  can  be  attained  by  the  most  careful  and  painstaking 
work  only. 

1  Howard  A.  Lothrop,  Stricture  of  the  Rectum:  A  Plastic  Operation  for  the 
Relief  of  Certain  Varieties,  Boston  Med.  and  Surg.  Jour.,  April  27,  1905. 


106 


THE    ABDOMEN 


A  word  about  tumors  of  the  anus:  tlicv  may  be  benign  and  they 
may  be  malignant.  Al)out  the  anus  are  found  condylomata,  especially 
in  women,  and  tlu>se  condylomata  are  due  to  in-itation  from  gonorrheal 
discharges.  Considerable  tumor  masses  foim,  which  may  be  mistaken 
for  cancer,  but  the  masses  do  not  infilti-ate  the  skin.  Histologically, 
they  appear  as  papillomata.  These  condylomata  may  be  excised  safely 
and  satisfactoril}'. 

Cancer  of  the  anus  is  found  in  rare  cases.  Cancer  here  begins  a 
good  deal  as  does  cancer  of  the  lip.  But  cancer  of  the  anus  grows 
rapidly,  in\-olYing  the  skin  rather  than  the  mucosa,  often  completely 

surrounding  the  anus.  The  inguinal 
glands  and  the  glands  about  the  ischiatic 
nerve  are  affected  early. 

The  only  effective  treatment  is  a  wide 
and  thorough  excision,  such  as  will  be 
described  in  dealing  with  cancer  of  the 
rectum. 

Coming  to  tumors  of  the  rectvun 
proper,  we  find  that  benign  groidhs  are 
not  especially  uncommon,  and  that  these 
may  be  grouped  in  two  classes — a  con- 
nective-tissue group  and  an  epithelial 
group.  The  former  group  is  seen  to  de- 
velop in  the  muscular  tissue  of  the  rectum 
— fatty  tumors,  myomata,  and  fibromata. 
Angiomata  have  been  reported,  and  one 
finds  rarely  echinococcus  and  dermoid 
cysts. 

All  these  tumors  give  rise  to  pain  and 
constipation  and  may  readily  be  dis- 
covered by  digital  or  visual  investigation. 
Frequently  they  may  be  removed  with- 
out opening  the  rectal  canal. 

Of  the  epithelial  benign  tumors,  aden- 
oids or  mucous  polypi  are  the  most  com- 
mon.    They  develop  in  the  lower   third 
of  the  rectum,  and  may  be  harmless  or  may  give  rise  to  a  trouble- 
some catarrh  associated  with  tenesmus   and  hemorrhage.      They  are 
seen  generally  in  children,  but  are  often  overlooked. 

They  may  be  snipped  off  or  carefully  excised,  and  the  pedicle  or 
resulting  wound  ligated  or  stitched.  Unfortunately,  these  growths 
tend  to  recur  and  multiply,  so  that  their  removal  results  in  temporary 
relief  only.     They  are  not  common. 

There  is  a  rare  form  of  papilloma  of  the  rectum  seen  in  adults;   it 
resembles  a  mucous  polyp,  but  may  be  mistaken  for  cancer.     It  has  a 
broad  base,  but  does  not  infiltrate  the  mucosa. 
Treatment  is  by  excision  and  cautery. 
Cancer  of  the  Rectum. — Many  competent  surgeons  still  feel  that 


Fig.  41. — Benign  tumors  of 
the  rectum  (after  von  Berg- 
mann). 


TUMORS  OF  THE  ANUS  AND  RECTUM 


107 


cancer  of  the  rectum  is  always  an  incurable  disease,  and  is  susceptible 
of  ])alliative  treatment  onl}-.  This  view  is  justified  by  the  fact  that  a 
large  majorit}^  of  patients  suffering  from  cancer  of  the  rectum  consult 
a  physician  only  after  the  time  during  which  radical  measures  are 
practicable.  At  the  best,  a  radical  operation  is  difficult  and  dangerous, 
and  to  insure  success,  should  be  undertaken  early  in  the  disease.  A 
few  recent  statistics  are  slightly  encouraging,  if  one  may  trust  statistics. 
W.  P.  Petersen,^  of  Heidelberg,  reports  operations  upon  248  cases  of 
rectal  cancer,  with  a  mortaHty  of  13  per  cent.;  permanent  cure,  18  to 
20  per  cent. — that  means,  patients  living  over  ten  years.  John  A. 
Hartwell  -  reports  46  cases  with  an  operative  mortalit}'  of  26  per  cent. 
Hupp  ^  analyzes  881  cases  with  a  mortality  of  9.4  per  cent.  But  re- 
ports vary  in  their  estimates,  some  finding  the  mortality  from  operation 
to  be  as  high  as  70  per  cent. 

Cancer  of  the  rectum  is  composed  of 
cj'lindric  cells  like  the  epithelium  from  which 
it  grows.  Adenoma  develops  from  the  lining 
of  the  crypts  of  Lieberkiihn.  Early  the  ad- 
enomata may  appear  benign,  but  soon  they 
take  on  malignant  characteristics. 

AYe  may  divide  true  cancer  of  the  rectum 
into  three  groups  histologically:  (1)  Carcin- 
oma of  the  rectal  wall  in  the  ampulla,  the 
commonest  cancer  of  the  rectum,  making  up 
about  65  per  cent,  of  all  the  cases.  This  is 
adenocarcinoma,  and  is  generally  found  on 
the  anterior  waU,  just  above  the  anus.  (2) 
Fibrous  tumors,  high  above  the  pouch  of 
Douglas,  from  2  to  3J  inches  above  the  anus. 
These  tumors  are  hard,  and  vary  in  size  from 
a  walnut  to  an  egg.  These  are  the  tumors 
which,  encircle  the  bowel  early  and  produce 
stenosis.  This  group  comprises  about  23  per 
cent,  of  the  whole,  and  one  remembers  of 
them  that  these  high-seated  tumors  form  a 
ring  of  stenosis.  (3)  The  third  group  is  the 
most  malignant,  but  the  least  common — 
from  12  to  15  per  cent,  of  all.  These  growths 
are  of  a  mucoid  nature;  they  develop  in  and 
envelop  the  lower  portion  of  the  rectum ;  they  spread  superficially  and 
infiltrate  the  deeper  tissues.  Necrosis  of  these  masses  is  seen  commonh'; 
and  on  inspection  there  appears  a  blood}^  gangrenous  tube,  substituted 
for  the  normal  rectum. 

The  lymphatic  connections  of  rectal  cancer  are  of  vital  importance 
to  the  surgeon,  because  upon  a  knowledge  of  lymphatic  extension 
depends  the  feasibility  of  successful  excision.     There  are  4  lymphatic 

1  Proceedings  German  Surgical  Congress,  1903;   Ann.  Surg.,  December,  1903. 

2  Ann.  Surg.,  September,  1905.  3  Med.  News,  September  28,  1901. 


Fig.  42. — Scirrhus  cancer 
of  the  rectum,  i^von  Berg- 
mann). 


108  THE    ABDOMEX 

connections:  (1)  Those  draining  the  anal  skin;  (2)  the  intermediate 
zone  of  the  anal  portion;  (3)  the  columnar  zone  of  the  anal  portion; 
(4)  the  group  draining  the  rectum  proper.  Evidence  of  involvement 
of  group  1  may  be  found  in  the  inguinal  nodes.  The  other  three  groups 
drain  upward  into  the  nodes  in  the  sacral  hollow  and  along  the  superior 
hemorrhoidal  arter}'.  Remember  this  important  fact,  however,  that 
all  4  of  these  groups  have  a  liberal  anastomosis,  so  that  disease  of  any 
portion  of  the  rectum  may  result  in  the  involvement  of  other  portions 
and  in  the  enlargement  of  any  one  of  these  h^mphatic  groups. 

Here  are  a  few  interesting  statistics  to  be  noted  in  passing:  Cancer 
of  the  rectum  causes  about  0.3  per  cent,  of  all  deaths;  it  is  twice  as  com- 
mon in  men  as  in  women.  It  is  seen  most  frequently  after  forty, 
but  cases  as  j'oung  as  twenty-three  are  reported.  Indeed,  it  is  a  re- 
markable fact  that  rectal  cancer  has  been  known  in  children  below 
ten  years  of  age. 

Symptoms. — The  early  s^onptoms  of  cancer  of  the  rectum  are  so 
indefinite  that  we  cannot  wonder  at  delay  in  establishing  a  diagnosis. 
The  early  S3'mptoms  are  slight  pain  and  bleeding  and  are  not  character- 
istic; often  they  are  so  indefinite  as  to  cause  a  patient  no  special  in- 
convenience; often  they  simulate  the  symjDtoms  of  other  lesions; 
most  commonly  they  suggest  hemorrhoids.  Later,  there  may  be  a 
sense  of  fulness  and  increasing  constipation.  Later  still,  when  the  disease 
is  well  advanced,  there  are  fairly  constant  pain,  hemorrhage,  a  foul 
discharge  with  gangrenous  odor,  and  the  evidence  of  more  or  less  com- 
plete intestinal  obstruction.  Constitutional  disturbance  is  not  a 
marked  feature  early;  indeed,  in  the  46  cases  reported  by  Hartwell 
cachexia  w^as  present  in  only  one-third  at  the  time  of  the  operation. 
So  it  is  evident  that  the  diagnosis  rarely  can  be  made  early — seldom 
in  less  than  nine  months  from  the  onset  of  symptoms;  often  as  late  as 
two  5'ears.  These  cancer  cases  emphasize  again  the  extreme  impor- 
tance of  making  a  careful  examination  of  eveiy  patient  who  complains 
of  constant  rectal  disturbance.  Age  signifies  little,  as  cancer  of  the 
rectum  may  occur  in  youth.  Pain  and  occasional  hemorrhage  always 
should  be  investigated,  and  the  diagnosis  confirmed  by  digital  explora- 
tion or  by  ini^pectiou  with  the  proctoscope. 

Treatment  of  Rectal  Cancer. — Ob^^ously,  no  mild  measures  will 
avail  in  cancer  of  the  rectum  unless,  indeed,  the  patient  and  his  friends 
prefer  that  he  content  himself  with  the  euthanasia  produced  by  opium 
— perhaps  the  preferable  method  in  a  majority  of  cases.  The  question 
of  methods  of  operation  is  one  which  has  occasioned  wide  and  rather 
hot  discussion,  its  answer  depending  probabty  upon  the  notions  and 
personal  experiences  of  individual  operators.  The  surgeon  has  to 
regard  3  factors  in  the  problem  :  he  must  remove  the  cancer  entire; 
he  must  combat  sepsis;  he  must  supply  a  satisfactoiy  artificial  anus. 
The  first  point  rarely  is  met.  Cancer  usually  returns.  As  for  the 
second,  sepsis  is  common  after  all  operations  upon  the  rectum,  and  as 
for  the  third,  a  satisfactory  artificial  anus  rarely  is  secured. 

Let  us  consider  briefly  a  few  of  the  measures  emploj'ed  in  attempting 


TUMORS   OF   THE    ANUS   AND    RECTUM  109 

to  attain  these  desired  results.  It  has  come  about  that  there  are  3 
main  routes  by  which  cancer  of  the  rectum  is  approached :  (1)  Through 
the  perineal  or  anal  region;  (2)  through  the  sacral  region;  (3)  by  ab- 
dominal section. 

Approach  to  the  cancer  through  the  anal  region  gives  no  surety 
of  complete  and  successful  removal  of  the  tumor,  though  in  a  certain 
number  of  cases  success  is  attained.  By  this  route  the  involved  lym- 
phatics cannot  readily  be  reached,  and  the  employment  of  this  method 
is  no  more  rational  than  is  resection  of  the  cancerous  breast,  leaving 
the  lymphatic  connections  undisturbed. 

Resection  of  the  rectum  through  the  sacrum,  that  is,  by  removing 
a  portion  of  the  sacrum,  as  recommended  by  Kraske  and  others,  is  a 
fairly  satisfactory  method.  Low-lying  cancer  may  thus  be  removed 
and  involved  lymphatics  traced.  But  an  incompetent  anus,  situated  in 
an  inaccessible  region,  nearly  always  results. 

The  method  to  be  preferred  is  extirpation  through  the  combined 
abdominal  and  sacral  or  anal  rovites.  It  is  needless  here  to  discuss 
at  length  the  various  arguments  advanced  by  advocates  of  various 
methods.  Suffice  it  to  suggest  that  the  abdominal  route  makes  pos- 
sible a  cleaner  dissection,  with  less  chance  of  sepsis,  and  establishes 
a  fairly  controllable  artificial  anus  in  an  accessible  region;  but,  most 
important  of  all,  it  provides  an  aseptic  field,  and  renders  possible  a 
complete  removal  of  the  growth  and  a  comparatively  easy  reaching 
of  the  h'mphatic  channels.  Bear  in  mind  this  important  point  also, 
that  inasmuch  as  all  the  rectal  lymphatics  anastomose  with  more 
or  less  freedom,  therefore  cancer  situated  in  any  portion  of  the  rec- 
tum, from  anus  to  sigmoid,  may  give  rise  to  cancerous  lymph-nodes 
in  any  of  the  -i  lymphatic  drainage  channels  which  I  have  described. 
Above  aU  things,  the  practitioner  must  remember  that  the  presence 
of  metastasis  in  other  organs,  notably,  the  liver,  positively  forbids  ex- 
cision of  the  rectum.  Through  abdominal  section  only  can  such  metas- 
tases be  found. 

All  operations  for  cancer  of  the  rectum  are  difficult — not  lightly  to 
be  undertaken.  The  surgeon  must  have  an  exact  knowledge  of  the 
anatomy  of  the  parts  and  an  intelligent  comprehension  of  his  patient's 
general  condition.  At  the  best,  both  surgeon  and  patient  are  embark- 
ing upon  a  forlorn  hope. 

The  patient  must  be  carefully  prepared,  whatever  the  operation 
employed,  and  a  daily  treatment  of  the  bowels,  for  from  one  to  two 
weeks,  is  in  order,  that  the  passage  may  be  completely  cleared.  Everj^ 
morning  before  breakfast  half  an  ounce  of  castor  oil  should  be  given, 
followed  by  an  enema.  The  diet  should  consist  of  meat,  eggs,  and 
strong  soups.  For  two  days  before  operation  the  patient  should  be 
hniited  to  a  liquid  diet,  and  should  be  given  opium.  The  last  enema 
should  be  given  not  later  than  six  hours  before  the  operation. 

The  Anal  Resection. — With  the  patient  on  his  back  and  his  knees 
drawn  up,  the  sphincter  is  dilated  or  divided  posteriorly  from  anus  to 
coccyx  (Kocher  removes  the  cocc3'x),  and  the  new-growth  is  seized  and 


110  THE    ABDOMEN 

excised  with  knife,  scissors,  or  Paquclin  cautery.  Bleeding  is  controlled, 
the  gap  is  sutui'ed,  the  posterior  cut  being  drained  with  gauze,  while  a 
tube  is  left  in  the  rectum. 

A  more  complete  method  is  approach  through  the  perineum.  The  in- 
cision is  made  from  the  middle  of  the  perineum  to  or  through  the  coccyx, 
encircling  the  anus.  The  anus  and  lower  portion  of  the  rectum  are  then 
carefully  separated  from  surrounding  tissues,  when  the  bowel  with  the 
new-growth  is  drawn  downward,  bringing  with  it  the  branches  of  the 
middle  hemorrhoidal  artery,  which  must  be  tied.  By  proceeding  care- 
fulh*  in  this  manner,  which  usvially  involves  opening  the  peritoneal 
cavity,  the  rectum  may  be  brought  well  down  and  cut  off  above  the 
growth.  The  final  step  consists  in  suturing  the  stump  of  bowel,  W'ith- 
out  too  much  tension,  into  the  wound,  and  packing  around  it  with 
gauze  to  control  hemorrhage.  This  method  with  various  modifications 
is  still  frequently  employed,  but  the  danger  from  sepsis  is  great,  and  there 
is  no  possibility  of  removing  thoroughly  infected  lymph-nodes. 

The  Sacral  or  Dorsal  Method.— Various  operators,  from  Kocher,  in 
1874,  have  advised  dorsal  methods  of  approaching  disease  of  the  rectum; 
but  to-day  the  most  commonly  accepted  course  is  that  advised  by 
Kraske  in  1885.  The  patient  lies  upon  his  right  side,  w^ith  his  thighs 
sharply  flexed,  and  an  incision  is  made  in  the  middle  line,  from  the  anus 
to  the  sacrum,  and  from  there  along  the  left  border  of  the  saciTim  to 
the  posterior  iliac  spine.  The  gluteus  maximus  is  divided,  and  hemor- 
rhage is  checked.  Then  the  sacrosciatic  ligaments  are  divided  close 
to  the  sacrum,  nearly  to  the  sacro-iliac  synchondrosis.  The  lateral 
sacral  arteries  are  secured,  but  the  pubic  nerve  and  vessels  must  not 
be  injured.  The  cocc3^x  is  then  cleared  or  removed,  and  the  rectum 
exposed,  ^"arious  operators  remove  varying  portions  of  the  sacrum. 
The  presacral  tissues  as  high  up  as  the  second  vertebra  are  pushed  away 
from  the  bone,  saving  the  sacral  nerves  only.  In  this  way  one  includes 
all  the  lymphatic  nodes  and  vessels  which  are  a})t  to  be  involved.  Search 
must  then  be  made  for  the  superior  hemorrhoidal  arterj-,  which  lies  in  a 
fold  of  peritoneum  behind  the  upper  portion  of  the  rectum.  After  ligating 
this  artery  the  gut  is  freed  posteriorly  and  laterally  and  the  peritoneum 
is  opened.  Then,  beginning  well  above  the  growth,  the  rectum,  with  its 
associated  nodes,  is  removed  from  above  downward,  intestinal  clamps 
having  been  placed  upon  it  at  the  point  of  section.  The  whole  of  the  rec- 
tum below  the  point  of  section,  and  including  the  anus,  should  be  ex- 
cised; then  the  proximal  portion  of  bowel  is  brought  out  and  fastened  in 
the  sacral  wound,  provision  being  made  at  the  same  time  for  ample 
gauze  drainage  of  the  surrounding  parts. 

So  much  for  two  of  the  methods  commonh'  employed. 

Combined  Method  of  Resection. — A  method  of  operating  in  two  stages, 
and  approaching  the  growth  from  above  and  from  below,  is  growing  in 
favor  and  promises  to  improve  our  statistics  as  regards  both  operative 
risk  and  permanent  cure. 

The  question  of  operation  by  the  combined  method  involves  also 
a  discussion  of  palliative  measures.     Such  measures  are  employed  when 


TUMORS  OF  THE  ANUS  AND  RECTUM  111 

total  resection  of  the  tumor  is  impossible,  when  obstruction  is  nearly 
or  entirely  complete,  and  when  pain  is  constant.  Palliation  consists 
in  establishing  an  artificial  anus  by  colostomy.  It  used  to  be  known 
as  Littre's  operation,  and  has  been  in  use  for  generations.  The  com- 
bined method  of  excision  of  the  rectum  is  by  two  stages,  and  takes 
advantage  of  a  prehminary  colostomy.  By  this  preliminary  measure 
the  bowel  is  efficiently  drained,  and  the  patient's  general  health  is 
improved,  because  a  sufficient  nutritious  diet  may  be  administered 
up  to  the  time  of  the  final  operation,  while,  owing  to  the  previous  colos- 
tomy, septic  absorption  is  diminished  or  eliminated  when  the  rectum  is 
removed.  In  addition  to  Kocher's  method  of  forming  an  artificial  anus, 
already  described,  another  satisfactory  method  is  to  bring  out  the  sig- 
moid in  the  left  groin,  to  cut  it  oft',  leaving  a  voluminous  pouch  of  bowel 
above,  to  draw  the  proximal  end  beneath  the  anterior  sheath  of  the 
rectus  muscle,  and  to  estabhsh  the  new  anal  opening  above  the  pubes 
in  the  median  line.  After  this  first  operation  the  patient  generally 
mends  in  surprising  fashion,  and  he  often  declares  himself  to  feel  entirely 
relieved. 

If  it  is  now  determined  to  proceed  to  more  radical  measures,  the 
second  step  is  taken  after  an  interval  of  from  two  to  three  weeks.  This 
second  step  may  be  entered  upon  variously.  The  abdomen  ma}*  be 
opened  from  above  at  the  same  time  that  the  sacral  route  is  followed 
from  below,  and  so  a  complete  and  thorough  dissection  of  the  pelvis 
may  be  accomplished.  If  the  abdomen  is  opened,  the  superior  hemor- 
rhoidal arteiy  must  be  tied  at  once,  and  in  all  cases  the  ureters  must  be 
identified  and  isolated.  Section  of  the  ureters  is  a  grave  calamity, 
which  has  happened  in  many  cases. 

The  best  position  for  the  patient,  for  approach  by  the  sacral  route, 
is  in  the  exaggerated  knee-chest  posture,  which  controls  remarkably  the 
venous  oozing.  Many  operators  prefer  to  work  entirely  along  the  sacral 
route,  and  not  to  open  the  abdomen  from  above  at  the  time  of  this 
second  operation.  Probably  this  method  involves  less  risk  of  sepsis. 
The  method  then  is  quite  similar  in  technic  to  that  of  Kraske.  The 
rectum  may  be  drawn  down  after  the  superior  hemorrhoidal  artery  is 
Hgated,  until  the  blind  end,  which  was  tied  off  at  the  preliminary  opera- 
tion, has  been  delivered.  This  elimination  of  the  whole  lower  bowel, 
lea\Tiig  no  blind  pouch  behind,  is  probably  the  best  method  of  opera- 
tion. Thus  the  entire  mass  is  completely  excised,  and  the  entire  rectum 
is  removed,  with  its  attached  glands  and  lymphatics,  down  to  and  in- 
cluding the  anus.  The  peritoneum  is  then  closed,  and  the  superficial 
wound  sutured  about  a  small  drain,  which  must  be  left. 

There  is  always  considerable  shock  following  these  operations,  so 
that  the  patient  must  be  carefully  watched  afterward  and  symptoms 
must  be  met  as  they  arise.  Feeding  may  be  done  through  the  artificial 
anus  until  the  stomach  is  ready  to  take  care  of  nourishment. 

Numerous  modifications  of  the  combined  method  of  excision  have 
been  devised.     Powers  ^  recommended  operating  on  women  by  working 

^  C.  A.  PoTv-ers  (Denver),  Boston  Med.  and  Surg.  Jour.,  January-  21,  1904. 


112  THE    ABDOMEN 

from  above  and  through  the  vagina,  instead  of  through  the  sacrum; 
the  entire  rectum  is  thus  readily  removed.  This  method  is  essentially 
that  which  has  been  pojuilarizcnl  by  J.  B.  Murphy.  The  student  of  the 
literature  should  also  familiarize  himself  with  W.  J.  Mayo's  modifica- 
tion of  Maunsell's  method,  as  well  as  with  the  operation  of  Weir.^ 

All  these  operations  are  difficult  and  dangerous  at  the  best.  The 
immediate  mortality  is  high,  and  recurrence  is  conunon;  but  accumu- 
lating statistics  seem  to  show  that  in  the  hands  of  competent  surgeons, 
and  of  competent  surgeons  only,  excision  of  the  rectum,  especially  by  the 
combined  method,  holds  out  promise  of  a  radical  cure,  or  at  least  of 
relief  from  pain,  and  a  prolonged  remission  of  symptoms. 
1  Med.  News,  July  27,  1901. 


CHAPTER  IV 
THE  ESOPHAGUS,  STOMACH,  AND  DUODENUM 

We  have  made  some  study  of  the  intestines  and  rectum,  and  have 
been  able  to  arrive  at  a  general  understanding  of  such  of  their  diseases 
as  concern  the  surgeon ;  and  we  have  observed  this  supremely  important 
fact,  that  the  digestive  tract  is  continually  subjected  to  the  presence 
of  foreign  substances — food  and  the  products  of  digestion.  These 
substances  are  there,  indeed,  to  meet  physiologic  demands,  but  their 


Fig.  43. — a,  Bougies  or  sounds;  h,  bulbous  sounds;  c,  English  rubber  sound  with 
funnel  and  openings  at  the  tip;  d,  Trousseau's  olive-tipped  bougie  (Keen's  Sur- 
gery). 

mere  presence  is  at  times  an  irritation  to  the  organs,  and  always  they 
carry  with  them  malign  organisms.  The  non-functionating  gut  of 
a  fetus  is  practically  sterile;  the  active  gut  of  an  infant  or  of  an  adult 
is  loaded  with  bacteria,  capable  of  setting  up  the  most  severe  infections. 
Let  us  turn  now  to  the  upper  portions  of  the  alimentary  tube, — 
the  esophagus,  stomach,  and  duodenum, — and  note  the  diseases  which 

8  113 


114 


THE   ABDOMEN 


occur  in  them,  observing  that  in  spite  of  minor  differences  in  function 
all  parts  from  pharynx  to  anus  are  of  a  generally  similar  structure,  are 
subject  to  much  the  same  influences,  and  develop  similar  disease 
processes.  As  we  have  seen  that  inflammations,  obstructions,  and  new- 
growths  are  the  important  lesions  of  the  intestines,  and  as  we  shall  see 
later  that  ulcer  and  new-growths  are  the  important  lesions  of  the  stomach, 
so  we  must  now  observe  that  obstructions,  new-growths,  and  malformations 
are  the  imjjortant  lesions  of  the  gullet;  but  we  observe  at  the  same  time 
that  all  such  lesions  are  common  to  all  portions  of  the  alimentary  tract. 

The  Esophagus 

When  you  pass  a  tube  or  bougie  into  the  stomach  of  an  adult,  re- 
member that  the  average  distance  from  incisor  teeth  to  cardia  is  16 
inches.  Moreover,  as  the  trend  of  the  esophagus  is  gradually  from 
median  line  to  the  left  of  the  spinal  column,  the  operator  must  observe 

■  I 


Fig.  44. — Starck's  diverticulum  sound  (Keen's  Surgery). 

that  right  to  left  direction  in  passing  an  instrument  or  the  esophago- 
scope,  and  he  must  cut  upon  the  left  side  of  the  neck  in  the  operation 
of  esophagotomy.  The  commonly  employed  instruments  for  examin- 
ing the  esophagus  are  bougies  and  olive-tipped  probangs  of  graduated 
sizes.     By  their  use  strictures,  pockets,  and  diverticula  may  be  dis- 


Fig.   45. — Esophageal  stricture.      Shows  Schreiber's  dilating   sound   in   position 

(Keen's  Surgery). 

covered,  and  foreign  bodies  may  be  detected.  Various  forms  of  endo- 
scopes are  used  for  the  inspection  of  the  gullet,  but  the  most  satis- 
factory is  some  form  of  straight  instrument,  as  recommended  by  von 
Mikulicz.  By  any  of  these  instruments  it  is  possible  to  make  out  also 
the  rare  malformations,  congenital  occlusions,  and  fistulas. 


STRICTURE    OF    ESOPHAGUS 


115 


Fig.  46. — Von  Mikulicz  set  of  instruments  for  esophagoscopy. 

STRICTURE  OF  ESOPHAGUS 

Stricture  is  far  the  most  common  lesion  of  the  esophagus  with  which 
the  surgeon  has  to  deal,  and  in  exploring  for  stricture  the  beginner  must 
remember  that  there  are  4  normal  narro wings  in  every  esophagus — 
at  its  beginning,  behind  the    cricoid  cartilage,  opposite  the  tracheal 


Fig.  47. — Permanent  cannula  (after  von  Leyden-Ren vers). 

bifurcation,  and  at  the  cardia.  Moreover,  there  are  two  important 
varieties  of  stricture — mahgnant  and  cicatricial — the  latter  usually 
caused  by  some  corrosive  poison.  In  more  general  terms  these  stric- 
tures are  due  to  the  healing  of  an  ulcer — from  any  traumatism,  chronic 
inflammation,  tjTDhoid  ulceration,  syphiHs,  tuberculosis,  prolonged 
vomiting,  small-pox,  or  gout.  A  common  seat  of  stricture  is  at  one 
of  the  normal  esophageal  narrowings.     The  stricture  may  be  single 


116 


THK    ABDOMEN 


or  multiple,  clci)eiKliiig  on  the  cause.  Pressure  from  without,  as  by 
a  tumor,  may  cause  constriction,  but  this  is  not  properly  stricture; 
nor  must  the  surgeon  forget  that  form  of  dysphagia,  or  difficulty  in 
swallowing,  known  as  spasmodic  stricture,  commonl}-  of  a  hysteric 
nature,  and  freiiuently  relieved  by  the  passage  of  a  bougie. 


Fig.  48.^Symond's  esophageal  tube  (Keen's  Surgery). 

We  need  not  consider  in  detail  the  pathology  of  the  cicatricial  stric- 
tures. Suffice  it  to  remind  the  student  that  the  initial  injury  is  fol- 
low^ed  by  an  inflammatory  reaction  which  gradually  subsides,  with 
healing  by  granulation  and  the  production  of  a  firm  fibrous  cicatrix, 
whose  breadth  and  depth  depend  on  the  extent  of  the  original  injury. 


^^ 


Fig.  49. — The  window-plug  for  the  esophagoscope.  Upper  figure,  the  esophago- 
soope,  made  air-tight  by  tlie  window-plug.  Lower  figure,  the  winilow-plug,  e.xact 
size,  and  a  cross-section  of  the  esophagoscope,  actual  size.  The  plug  is  taken  out 
and  inserted  at  will.i 

The  symptoms  will  vary  with  the  progress  of  the  disease.  Early 
there  are  pain,  distress,  and  a  sense  of  burning,  which  pass  in  a  few  days. 
Then,  as  the  gullet  lumen  contracts,  there  comes  difficulty  in  swallowing, 

1  "  This  is  the  tube  which  I  prefer.  It  should  be  called  the  Einhorn-Jackson- 
Mosher  tube.  The  window-plug  is  mine.  This  tube  for  adults  should  be  of  tivo 
lengths— 10  inches  and  18  inches."— Statement  by  H.  P.  Mosher. 


STRICTURE    OF    ESOPHAGUS 


117 


which   may  increase   until   Hqiiids  even  fail  to  pass;  but  the  tube  dis- 
tends above  the  stricture,  as  occurs  in  the  case  of  strictures  elsewhere. 


Fig.  50. — Method  of  introducing  esophageal  bougie.     Tlie  bougie  is  bent  before  it  is 
introduced  (Keen's  Surgery). 


Fig.  51. — Method  of  introducing  esophageal  bougie.      Position  I:   The  head  in  ex- 
tension until  the  bougie  reaches  the  esophageal  entrance  (Keen's  Surgery). 

Thus  the  esophagus  becomes  sacculated  and  the  sacculation  gradually 
attains  a  considerable  caliber,  so  that  quantities  of  food  lodge  there. 
From  time  to  time  the  patient   vomits  this   accumulated   material. 


118 


THE    ABDOMEN 


Sometimes  the  vomitus  is  bloody;  sometimes  it  is  composed  of  saliva 
and  mucus.  The  patient  becomes  feeble  and  emaciated.  He  suffers 
from  hung(>r  and  thirst.  There  may  be  pain  or  a  sense  of  discomfort 
in  the  region  of  the  stricture,  or  over  the  epigastrium  and  in  the  back. 


Fig.  52. — Method  of  introducing  esophageal  bougie.      Position  II:  The  chin  brought 
down  almost  to  the  chest;  the  bougie  glides  into  the  esophagus  (Keen's  SurgerjO- 

Such  a  history  points  to  the  diagnosis  of  esophageal  stricture,  of  which 
the  presence  is  confirmed  by  exploring  the  gullet  with  bougies. 

The  first  step  in  treating  these  strictures  is  to  ascertain  their  size. 
We  use  for  this  purpose  olive-tipped  bone  probangs,  taking  care  not 
to  damage  the  wall  of  the  gullet,  for  one  hears  dreary  tales  of  incautious 


GUIDE    BOUGIE  StHOLLOW  DILATING  BOUGIE 


S 


String  Tunnel 
Oesophagotome.  Oesophagotome     MoDiriED. 

Fig.  53. 


operators  who  have  passed  instruments  through  the  wall  of  the 
esophagus  into  the  trachea,  the  mediastinum,  and  even  into  the  aorta. 
If  the  stricture  will  admit  a  probang,  one  may  proceed  to  dilate  the 
narrow  opening  with  flexible  bougies  in  the  manner  illustrated  by  the 
figures.     In  this  way  most  strictures  may  be  dilated  readily,  and  when 


STRICTURE   OF   ESOPHAGUS 


119 


stretched  to  a  comfortable  size,  may  be  kept  open  by  the  occasional 
passage  of  an  instrument.  You  must  warn  the  patient  that  the  stric- 
ture is  liable  to  recur  unless  it  be  watched  and  treated  occasionally. 

Then  there  is  that  class  of  tight  strictures  on  which  Abbe  and  Mixter 
have  experimented,  and  for  which  Dunham  and  Plummer  have  devised 
their  ingenious  instruments.^  The  appended  cuts  (Figs.  53,  54,  55) 
show  graphically  the  technic  of  Dunham's  method,  which,  in  common 
with  man}'  other  surgeons,  I  have  used  with  satisfaction.  There  are  two 
distinct  sets  of  apparatus,  but  the  principle  of  both  is  the  same:  the 
stricture  is  saAved  through  with  a  thread.  The  first  apparatus  is  used 
for  strictures  through  which  a  guide  may  be  passed.  An  olive  tip  fol- 
lows and  engages  in  the  stricture.  Over  the  olive  there  plays  a  stout 
thread,  which  is  pulled  back  and  forth  against  the  stricture  until  it 
cuts  a  way  for  the  instrument,  which  is  then  pushed  on  into  the  stom- 
ach.    Anesthesia  is  not  needed. 


K. 


THREAD-WASHING 

THROUGH    MOUTH   AND  THROUGH   NOSTRIL. 


Fig.  54. 

Dunham's  second  apparatus  is  for  tight  strictures  which  will  not 
take  a  guide.  For  such,  a  preliminary  gastrostomy  is  necessary,  and 
this  artificial  opening  must  be  kept  open  until  after  the  secondary 
operation,  A  thread  is  then  washed  down  from  mouth  to  stomach, 
one  end  being  retained  above.  The  thread  end  in  the  stomach  is  then 
hooked  out,  and  a  stout  double  linen  thread  is  dra"^Ti  through  the  gullet. 
There  are  now  two  threads  in  the  esophagus.  By  one  a  'Svire-and- 
spindle  bougie"  is  drawn  up  against  the  stricture  from  below.  The 
other  thread  plays  over  and  alongside  of  this  bougie,  and  so  cuts  out  a 
path  for  the  larger  instrument. 

Dunham's  method  of  passing  the  first  thread  dovm  into  the  stomach 
is  curiously  mgenious:  The  thread  of  silk,  several  feet  long,  is  fed 
through  a  funnel  and  drinking  tube  into  the  mouth  of  the  patient,  who 

1  Theodore  Dunham,  New  Instruments  for  the  Treatment  of  Esophageal  Stric- 
ture, Ann.  Surg.,  1903,  vol.  xxxvii,  p.  350. 


120 


THE    AHDOMKN 


swallows  wiiter  slowly  poured  into  the  fuiin(>l.  The  descending  stream 
quickly  carries  the  thread  tlu()Ui;h  the  closest  and  most  tortuous  stric- 
tures into  the  stomach. 

When  a  stricture  has  been  sufficiently  dilated  by  this  method,  the 
gastrostomy  opening  is  closed,  and  a  patent  esophagus  is  maintained 
by  passing  a  bougie  occasionally — perhaps  two  or  three  times  a  year. 

Dunham's  method  is  applical)le  to  all 
strictures  through  which  a  stream  of  water 
can  pass.  In  the  case  of  impermeable  stric- 
tures, a  permanent  gastrostomy  is  required 
to  avert  starvation.  Mixter,  at  the  Massa- 
chusetts General  Hospital,  had  a  remark- 
able case  in  which  the  destructive  agent 
had  obliterated  not  only  the  lumen  of  the 
esophagus,  but  that  of  the  stomach  also. 
The  patient  is  now  comfortably  nourished 
through  jejunostomy,  and  he  thrives  after 
six  years,  his  only  complaint  being  that  he 
can  swallow  no  better  than  before  the  opera- 
tion! 


Artificial. 
Oesophagus. 


CARDIOSPASM 


TO  ILLUSTRATE 

THREAD-WASHING. 


Fig.  55. 


The  term  cardiospasm  has  been  applied 
in  recent  years  to  a  stricture  of  the  cardiac 
end  of  the  esophagus,  associated  with  dilata- 
tion of  that  tube.  It  is  probable  that  the 
term  ■  is  still  used  to  embrace  a  greater 
variety  of  esophageal  changes  than  should 
be  indicated  by  a  single  word.  We  know, 
for  example,  that  a  sudden  acute  spasmodic 
closure  of  the  cardia  may  take  place,  ex- 
actly resembling  a  spasmodic  closure  of  the 
P3'lorus.  This  sudden  closure  of  the  cardia 
is  called  acute  cardiospasm.  Furthermore, 
there  is  chronic  cardiospasm,  for  which  various  causes  are  assigned — 
kinking  of  the  esophagus,  esophagitis,  atony,  degeneration  of  the  fibers 
of  the  pneumogastric,  and  primary  long-continued  spasm.  The  last 
two  causes,  assigned  by  von  jMikulicz  and  Kraus,  may  very  well  co- 
exist, and  are  probably  the  most  common.  In  other  words,  we  see 
that  cardiospasm,  so  called,  may  be  acute  or  chronic,  may  be  j^rimary 
or  secondary. 

These  cases  usually  go  unrecognized  for  a  long  time.  At  first  the 
patients  are  thought  to  have  a  disease  of  the  stomach.  Again,  the 
diagnosis  of  cancer  of  the  esophagus  freciuenth'  is  made. 

The  symptoms  are  those  of  pressure  in  the  epigastrium,  and  fulness, 
which  is  relieved  by  vomiting,  while  the  vomitus  is  always  undigested 
food  containing  no  hydrochloric  acid,  pepsin,  or  rennet.  There  may 
be   dyspnea    and   hoarseness.     We   ascertain   the   exact   condition   by 


CARDIOSPASM 


121 


passing-  bougies  or  stomach-tubes,  which  may  or  may  not  engage  in 
the  stricture  and  pass  it  with  chfficulty.  The  Ilocntgen-ray  picture  is 
characteristic  if  the  suspected  pouch  be  filled  first  with  a  mixture  of 
potato  and  bismuth  porridge.  Best  of  all,  the  esophagoscope  gives  an 
excellent  picture  of  the 
condition. 

That  form  of  the  dis- 
ease with  which  surgeons 
are  most  specially  con- 
cerned is  the  chronic  foi'm. 
Chronic  cardiospasm  lasts 
many  years.  The  con- 
striction becomes  gradu- 
all}'  tighter  and  tighter; 
the  dilatation  of  the 
esophagus  greater  and 
greater,  the  patient's  nu- 
trition more  and  more  dis- 
turbed, until,  finally,  death 
from  starvation  results. 
Von  Mikulicz  believed  also 
that  cardiospasm  predis- 
poses to  cancer. 

The  treatment  is  symp- 
tomatic and  is  direct.  The 
symptomatic  treatment 
means  a  careful  dieting, 
abstinence  from  all  stimu- 
lants, and  daily  lavage 
with  astringents.  The 
local  application  of  cocain 
has  been  found  useful.  In 
the  case  of  acute  attacks 
with  complete  obstruction, 
rectal  feeding  may  be 
necessary,  or  gastrostomy 
even.  Various  ingenious 
devices  for  dilating  the 
stricture  have  been  em- 
ployed, and  are  undoubt- 
edly serviceable,  but  at 
the  best  they  seem  to  be 
palliative  merely.  Assum- 
ing the  disease  to  be  primary,  von  Mikulicz  cured  a  few  chronic  cases 
by  opening  the  stomach  and  forcibly  stretching  the  stricture.  The 
disease  is  coming  to  be  regarded  as  more  common  than  was  thought  a 
few  years  ago.  Certainly  the  complex  of  conditions  is  extremely  in- 
teresting, and  is  still  in  process  of  elucidation. 


Fig.  56. — Anatomic  preparation  from  a  case  of 
cardiospasm  with  saccular  dilatation  of  the  esoph- 
agus. A  drainage-tube  is  seen  in  the  cardiac  seg- 
ment (Keen's  Surgery). 


122 


THE    ABDOMEN 


DIVERTICULUM   OF   THE   ESOPHAGUS 

Diverticulum  of  the  esophagus  is  a  condition  cHnically  aUied  to 
stricture  at  times.  That  is  to  say,  its  sj-mj^toms  may  simuhitc  those  of 
stricture.  Moreover,  we  are  coming  to  beheve  that  it  is  a  rather  com- 
mon condition.  M.  H.  Richardson,  writing  eight  years  ago,  stated 
that  a  search  through  the  literature  disclosed  but  56  cases  of  esophageal 
diverticulum;  on  the  other  hand,  Riebold  ^  says  that  such  diverticula 
have  been  found  in  3.5  per  cent,  of  all  autopsies  in  adults,  but  that 
they  have  never  been  seen  in  children  under  fifteen  years.  Be  all 
that  as  it  may,  no  one  surgeon  can  point  to  a  great  list  of  these  cases. 


Fig.  57. — Diverticulum  of  esophagus  (after  Ricliardson). 


Diverticula  are  pouches,  varying  in  size,  springing  from  some  portion 
of  the  esophagus,  and  somewhat  resembling  a  gall-bladder  in  shape. 
A  true  diverticulum  is  lined  with  mucous  membrane.  There  are  three 
varieties — traction  diverticula,  due  to  the  adhesions  and  pulling  of 
scars  external  to  the  esophagus;  pressure  diverticula  (sometimes 
called  pulsion  diverticula),  due  to  pressure  from  within;  and  traction- 
pressure  diverticula.  These  diverticula  are  variously  placed,  but  most 
commonly  are  found  at  the  junction  of  the  pharynx  and  esophagus. 
Rarely  they  are  as  low  as  the  mediastinum.  Generally,  they  lie  behind 
the  esophagus,  between  it  and  the  spinal  column. 

Diverticula  may  or  may  not  give  rise  to  s5anptoms,  which  will 

1  Virchow's  Arch.,  vol.  clxxiii,  No.  3. 


FOREIGN   BODIES    IN   THE    ESOPHAGUS 


123 


depend  on  the  site  of  the  opening,  the  size  of  the  diverticulum,  and  its 
capacity  for  incommoding  by  pressure.  Symptoms  may  vary  all  the 
way  from  a  sense  of  thickness  in  the  throat  and  a  tendency  to  clear 
away  nnicus,  to  dysphagia,  nausea,  vomiting,  and  sundry  pains  due 
to  pressure  by  the  distended  pouch.  Sometimes  a  tumor  is  seen  in 
the  side  of  the  neck,  and  the  swelling  may  be  obliterated  by  pressure; 
sometimes  there  is  no  tumor  apparent.  Sometimes  the  diverticulum 
fills  with  food  before  food  will  pass  to  the  stomach.  Frequently  a 
bougie  will  not  pass  into  the  stomach  unless  the  pouch  is  full  of  food. 
Erroneously,  this  has  been  asserte^cl  to  be  an  invariable  sign.  The 
stethoscope  may  detect  fluids  passing  into  the  pouch.  Mix  food  with 
bismuth  subnitrate  and  allow  the  patient  to  swallow  it  into  the  divertic- 
ulum, when  a  satisfactory  skiagraph  of  the  pouch  may  be  taken. 


Fig.  58. — Diverticulum  of  esophagus  (after  Richardson). 

Treatment. — The  only  radically  satisfactory  treatment  of  divertic- 
ulum is  by  excision,  when  the  sac  is  within  surgical  reach.  Cut  down 
on  the  left  side  of  the  neck,  directly  over  the  sac;  cut  off  the  sac,  cau- 
terize the  stump,  turn  it  in,  and  complete  the  operation  with  a  row 
of  Lembert  stitches  in  the  esophageal  wall.  A  small  diverticulum, 
without  being  opened,  may  be  inverted  into  the  esophagus.  Avoid 
always  the  recurrent  laryngeal  nerve.  Sew  up  the  wound  with  drain- 
age. Dress  the  wound  with  an  extra  large  absorbent  dressing,  and 
fix  the  head  for  five  days  in  a  Thomas  collar.  For  the  first  three 
days  after  operation  give  no  food  by  mouth. 


FOREIGN  BODIES  IN  THE  ESOPHAGUS 

Regarding  foreign  bodies  in  the  esophagus,  an  abundance  has  been 
written.     Yet  the  subject  is  simple.     It  has   attracted  a  multitude 


124 


THE   ABDOMEN 


of  writers,  because  foroif2;n  bodies  in  the  esophagus  are  a  commonplace 
of  practice.  All  sorts  of  objects,  from  coins  and  fish-bones  to  open 
safety-pins  and  plates  of  false  teeth,  have  lodged  in  the  esophagus. 
When  they  lodge  and  stick,  they  make  trouble.  D.  \\'.  Cheever,  one 
of  the  first  of  American  surg(>ons  to  perform  esoijhagotomy,  delivered 
a  famous  lecture  on  thit^  tojjic.  Foreign  bodies  make  trouble  because 
they  obstruct  the  passage  of  food,  primarily,  and  because  they  damage 
seriously  the  esophagus,  secondaril3^  They  damage  the  esophagus 
either  by  wounding  it  sharply,  rarely  by  passing  through  it,  or  by  setting 
up  an  ulcerative  process,  leading,  if  unrelieved,  to  extensive  and  alarm- 
ing inflammation.  The  student  must  remember  that  most  foreign 
bodies  lodge  commonly  at  one  of  the  points  of  physiologic  constriction, 


Fig.  .59. — Esophageal  instniments:  a,  h,  Forceps;   c,  horsehair  probang;  (/,  coin- 
catcher;  e,  esophageal  bougie. 


but  small  sharp  articles,  like  fish-bones,  catch  in  the  tonsils  usually. 
In  any  case  foreign  bodies  should  be  removed  as  soon  as  possible. 

As  to  treatment,  there  are  obviously  three  methods  of  extracting 
foreign  bodies;  through  the  mouth,  through  the  stomach,  and  through 
the  neck  by  esophagotomy.  A  great  many  substances  may  be  pulled 
up  or  pushed  down  by  proper  instruments  introduced  through  the 
mouth — bougies,  coin-catchers,  the  umbrella  probang;  though  one 
must  remember  that  these  measures  are  not  altogether  devoid  of  danger, 
as  coin-catchers  have  been  known  to  stick  or  break  off  in  the  gullet. 
For  this  reason  it  is  well,  if  possible,  to  obtain  a  sight  of  the  foreign 
body  with  the  esophagoscope  or  the  .r-ray.  M.  H.  Richardson,  in 
1886,  was  the  first  to  demonstrate  the  feasibility  of  remo^•ing  foreign 


TUMORS   OF   THE    ESOPHAGUS  125 

bodies  through  the  stomach.  He  ch-ew  out  and  opened  the  stomach, 
passed  in  a  forceps,  and  removed  a  phitu  of  false  teeth  lodged  just  above 
the  cardia.  Bodies  may  also  be  removed  from  the  eso]jhagus  by  passing 
down  a  large-sized  endoscope,  such  as  is  used  in  the  urethra,  and  grasp- 
ing the  offending  object  with  pliers  introduced  through  the  endoscope. 
Failing  other  means,  one  may  employ  esophagotomy,  which  consists 
in  opening  the  esophagus  on  the  left  side  of  the  neck  in  the  region  of 
the  anterior  belly  of  the  omohyoid  muscle.  Through  such  an  opening 
the  esophagus  may  be  explored  with  the  finger  or  with  instruments,  and 
any  foreign  body,  except  the  most  low  lying  and  firmly  impacted,  may 
thus  be  removed.  Esophagotomy  is  followed  commonly  by  slow 
healing  and  an  infected  w^ound.  The  esophagus  may  be  stitched  up 
with  catgut,  and  the  external  wound  drained.  Various  other  ingenious 
devices  have  been  employed  in  special  cases,  but  the  main  principles 
are  those  already  laid  down. 

TUMORS  OF  THE  ESOPHAGUS 

Tumors  of  the  esophagus  are  common ;  next  to  benign  stricture  and 
foreign  bodies,  they  constitute  the  most  important  and  interesting 
group  of  lesions  of  the  esophagus  with  which  the  surgeon  has  to  deal. 
Benign  tumors  are  not  common,  but  cancer  is  a  frequent  affection,  as 
one  would  expect  w^hen  dealing  with  an  organ  so  subject  to  traumatism 
as  is  the  esophagus. 

Of  the  benign  tumors,  one  should  remember  that  cysts,  'papillomata, 
myomata,  and  polypi  are  occasionally  found,  and  may  prove  trouble- 
some. Ivlebs  points  out  the  interesting  analogy  between  diseases  of 
the  esophagus  and  those  of  the  external  skin.  These  various  benign 
tumors  may  cause  slight  or  marked  symptoms.  The  important  evi- 
dence of  their  presence  is  difficulty  in  swallowing;  but  one  can  estabHsh 
a  positive  diagnosis  by  the  esophagoscope  only.  Obviously,  these 
tumors  can  be  removed  by  surgical  measures  alone — by  snaring,  by 
excision,  or  by  the  cautery,  when  they  are  within  reach;  or  they  may 
be  approached  through  esophagotom3^ 

Sarcoma  of  the  esophagus  rarely  occurs.  It  runs  a  rather  rapid 
course  and  is  uniformly  fatal.  Any  attempt  at  treatment  must  be  along 
the  lines  to  be  suggested  for  cancer  of  the  esophagus. 

Cancer  of  the  esophagus  ^  is  one  of  the  most  grievous  and  fatal 
diseases  known.  We  see  it  in  daily  practice  and  in  every  surgical  ward. 
Its  site  is  generally  at  one  of  the  normal  esophageal  narro wings,  especi- 
ally behind  the  cricoid  and  just  above  the  cardia.  It,  too,^  causes 
dysphagia  as  a  first  symptom — dysphagia  which  may  steadily  increase 
from  the  beginning  until  there  is  complete  occlusion,  or  rarely  may 
appear  late  in  the  disease  only.  That  depends  on  the  anatomic  arrange- 
ment of  the  cancer,  whether  it  encircle  the  gullet  or  grow  to  a  considera- 
ble size  without   encroaching  specially  upon  the   lumen.     Gnawing, 

1  For  an  admirable  recent  bibliography  on  cancer  of  the  esophagus  see  the 
article  by  M.  G.  Seelig,  Ann.  Surg.,  December,  1907,  p.  809. 


126  THE   ABDOMEN 

continuous  pain  often  is  present — sometimes  over  the  seat  of  the  disease, 
sometimes  in  the  epigastrium  or  between  the  shouklcr-V^lades.  Of 
course,  one  observes  also  the  rapid  cachexia,  more  pronounced  than 
cachexia  of  cancer  elsewhere,  because  starvation  is  added  to  the  toxic 
process.  In  other  respects  encircling  or  occluding  cancer  causes  symp- 
toms similar  to  those  of  benign  stricture — the  spitting  up  of  undigested 
food  and  occasionally  bloody  or  foul  expectoration.  The  patient's 
breath  is  noticeably  offensive.  Moreover,  when  cancer  of  the  esophagus 
is  low  lying,  it  may  involve  the  fundus  of  the  stomach  and  give  rise  to 
a  train  of  symptoms  resembling  those  of  gastric  cancer. 

From  the  history  of  cachexia,  emaciation,  pain,  and  obstruction 
a  diagnosis  of  cancer  can  be  made  almost  with  certainty.  Of  course,  a 
positive  diagnosis  is  of  great  importance,  and  to  establish  this,  the 
esophagoscope  is  useful  sometimes;  or  bits  of  tissue  may  be  removed 
with  the  sharp  spoon  or  the  tip  of  an  esophageal  instrument. 

Treatment  is  by  palliation.  I  have  rarely  seen  a  cancer  of  the 
esophagus  which  lent  itself  to  an  attempt  at  radical  removal.  Pallia- 
tive measures  include  morphin,  the  passage  of  bougies,  and  in  a  few 
cases  the  insertion  of  a  hollow  tube  to  be  worn  permanently.  If  there 
be  complete  obstruction  and  if  the  patient's  strength  permit,  one  may 
stave  off  starvation  by  establishing  a  peraianent  feeding-opening  in 
the  stomach — gastrostomy.  The  old  routine  in  all  cases  of  esophageal 
stricture  of  doubtful  origin  is  to  give  a  course  of  potassium  iodid,  with 
syphilis  in  mind.  Sometimes  this  does  no  harm,  but  the  treatment 
should  not  be  continued  longer  than  two  weeks  if  no  benefit  results. 
Several  operators  have  performed  radical  removal  of  the  growth,  but 
no  case  of  permanent  cure  is  recorded.  Recent  experiments  have 
shown  that  it  is  feasible  to  enter  the  mediastinum  from  behind  and  to 
resect  the  esophagus  in  its  lower  portion,  the  Sauerbruch  cabinet  or 
some  similar  device  being  employed  at  the  same  time  to  favor  expan- 
sion of  the  lung.  At  the  present  writing  there  is  no  satisfactory  evi- 
dence that  such  procedures  promise  benefit  to  these  unfortunate  patients. 

INJURIES  OF  THE  ESOPHAGUS 

In  addition  to  the  diseases  of  the  esophagus  already  discussed,  there 
are  certain  other  conditions  with  which  the  surgeon  occasionally  may 
concern  himself.  There  are  injuries,  which  the  writers  are  wont  to 
treat  under  various  headings,  though,  in  fact,  I  have  already  referred 
to  this  subject  in  dealing  with  foreign  bodies  and  with  stricture.  In- 
juries due  to  foreign  bodies  explain  themselves.  I  have  seen  the 
esophagus  ruptured  by  a  fall  upon  the  head,  and  writers  report  cases 
of  rupture  of  the  esophagus  due  to  vomiting.  These  patients  almost 
always  die  from  sepsis,  but  the  effort  of  the  surgeon  must  be  to  provide 
proper  drainage  and  to  nourish  the  patient  without  irritating  the 
wounded  tissues. 


THE    STOMACH  127 

INFLAMMATIONS   OF   THE   ESOPHAGUS 

Inflammations  of  the  esophagus  occur  at  times  and  may  interest 
the  surgeon.  They  may  assume  various  forms,  such  as  acute  or  chronic 
catarrhs,  and  necrotic  or  diphtheric  inflammations.  These  inflamma- 
tions may  be  ascertained  by  the  use  of  the  esophagoscope.  Treat- 
ment is  rather  uncertain.  If  the  disease  is  mild,  relief  and  cure  follow 
the  administration  of  a  cool  liquid  diet  and  the  use  of  general  tonics. 
If  the  disease  is  more  severe,  it  may  be  necessary  to  make  local  applica- 
tions with  such  solutions  as  silver  nitrate  (1:4000)  or  a  5  or  10  per 
cent,  solution  of  argyrol. 

Ulcers  of  the  esophagus  occur  also — gangrenous  ulcers  caused 
by  pressure  from  within  or  from  without;  syphilitic  ulcers  in  the  upper 
portion;  rarely  tuberculous  ulcers;  and  actinomycosis  of  the  esophagus 
has  been  described.  It  appears  also  that  peptic  ulcer  of  the  esophagus^ 
may  be  found  as  well  as  the  curiously  uncommon  typhoid  ulcer. 

All  these  latter  lesions  are  curiosities  of  surgery.  They  can  be 
ascertained  by  the  use  of  the  esophagoscope,  and  by  the  recognition 
of  associated  general  disease,  while  their  treatment,  with  the  exception 
of  that  for  actinomycosis,  must  be  along  general  systemic  lines. 

The  Stomach 

The  stomach  has  become  an  organ  of  supreme  interest  to  surgeons 
in  these  days.  Within  the  past  ten  years  the  literature  of  gastric 
surgery  has  grown  to  enormous  dimensions;  and  advances  in  accuracy 
of  diagnosis,  in  confidence  of  treatment,  and  in  operative  technic  have 
been  in  proportion.  We  have  seen  how  the  appendix  with  its  various 
manifestations  of  disease  dwarfs  the  importance  of  most  other  ab- 
dominal organs,  and  how  its  disturbances  have  a  special  bearing  on 
digestive  disorders.  In  like  manner  the  stomach,  ulcerated,  catarrhal, 
or  the  seat  of  malignant  disease,  looms  up  as  an  organ  continually  sub- 
ject to  surgical  observation  and  treatment. 

Gastric  surgery  is  more  than  thirty  years  old,  but  for  the  first  fif- 
teen years  its  progress  was  halting  and  unsatisfactory.  So  long  ago 
as  1880  von  Mikulicz  sutured  a  perforation  on  the  lesser  curvature  of 
the  stomach,  but  the  patient  died,  and  in  the  year  previous  Pean  at- 
tempted a  pylorectomy, — unsuccessfully, — to  be  followed  by  Rydygier 
in  1880.  Billroth  improved  the  operation  and  saved  his  first  patient 
in  1881,  while  Rydygier  excised  successfully  an  ulcer  in  1881,  and  in 
the  same  year  Wolfler  performed  the  first  gastro-enterostomy. 

Up  to  that  time,  and  until  much  later,  indeed,  lesions  of  the  stomach 
were  regarded  as  belonging  to  the  domain  of  the  internist  acting  alone, 
but  of  recent  years  we  have  come  to  see  that  many  disorders  of  diges- 
tion are  due  to  anatomic  changes  which  disturb  the  stomach's  mechan- 
ism and  demand  mechanical  interference  for  their  relief.     For  instance, 

^  Peptic  Tilcer  of  the  esophagus  is  well  recognized  and  may  lead  to  stricture. 
Considerable  literature  on  this  subject  is  summed  up  by  Wilder  Tileston,  Peptic 
Ulcer  of  the  Esophagus,  Amer.  Jour.  Med.  Sci.,  August,  1906. 


]28 


THK    ABDOMKX 


a  narrowed  ])yl()rus  will  ahva}'s  ol^slnict  tlu;  onward  ])assa,i;o  of  food 
until  the  opening  has  been  enlarged  by  the  surgeon. 

Observe,  too,  the  vital  importance  of  associated  diseases  of  sundry 
abdominal  organs.  Such  association,  accompanied  with  misleading 
s^'uiptoms,  renders  extremely  difficult  the  physician's  task,  if,  on  the 
evidence  of  symptoms  alone,  he  attempt  to  name  a  particular  oi'gan 
as  the  one  at  fault.  Gastric  ulcer,  cholangitis,  pancreatitis,  and  peri- 
gastritis may  give  rise  to  identical  trains  of  symptoms.  The  recognition 
of  such  facts  has  led  to  the  conviction  that  diseases  of  these  various 
abdominal  organs  must  be  studied  together,  for  these  diseases  form  a 
complex  1)ut  interdependent  group. 

Another  important  point  in  considering  diseases  of  these  organs, 
which  we  group  under  the  name  digestive  organs,  is  that  they  all  bear 
a  definite  relation  to  the  duodenum.     The  duodenum  is  their  central 


KiDNay 


\app 


Fig.  60. — Diagrammatic  representation  of  the  organs  whicli  lie  near  or  are  drained 

through  tlie  duodenum. 


chamber  or  clearing-house.  The  stomach,  the  common  bile-duct,  and 
the  pancreatic  ducts  empty  into  it,  and  in  it  there  take  place  the  most 
important  digestive  changes.  Moreover,  through  an  interesting  ar- 
rangement of  the  intestinal  innervation,  disease  ofthe  vermiform  appen- 
dix causes  reflex  irritation  of  the  stomach;  while  ptosis  of  any  of  the 
abdominal  organs  may  set  up  a  great  variety  of  distressing  "  dyspeptic  " 
symptoms. 

Bearing  in  mind  then  the  close  anatomic,  physiologic,  and  patho- 
logic relations  of  the  abdominal  digestive  organs,  let  us  take  up  in  detail 
a  brief  consideration  of  stomach  and  duodenal  diseases,  so  far  as  they 
concern  surgeons. 

Ulcer  and  cancer  are  at  the  bottom  of  most  operable  gastric  dis- 
orders, but  we  must  name  also  the  complications  of  ulcer — pyloric 
obstruction;    gastrectasia,  or  dilatation  of  the  stomach;    hemorrhage; 


PEPTIC    ULCER  129 

distortion  of  the  stomach  (hour-glass  stomach);  adhesions;  tetany. 
Then  there  is  that  curious  condition,  spasm  of  the  pylorus;  stenosis  of 
the  pylorus  in  infants;  cirrhosis  and  gastroptosis. 

PEPTIC  ULCER 

It  is  probable  that  5  per  cent,  or  more  of  all  mankind  suffer  from 
gastric  or  duodenal  ulcer,  first  and  last.  The  precise  frequency  of  such 
ulcers  seems  impossible  to  determine,  however,  and  the  fact  that  scars 
of  old  ulcers  are  often  found  at  operations  and  postmortem,  when  the 
patient  gave  no  history  of  symptoms  pointing  to  ulcer,  suggests  that 
peptic  ulcer  is  more  common  than  has  been  supposed. 

The  cause  of  peptic  ulcer  is  still  a  matter  of  dispute,  though  the 
actual  condition  present  seems  to  be  a_localized  necrosis  acted  upon 
persistently  by  the  digestive  fluids.     Women  are  afflicted,  compared 


Fig.  61. — Acute  round  ulcer  with  perforation  (Warren  Museum,  Harvard,  8476). 

with  men,  in  the  proportion  of  six  to  four.  Age  has  an  extremely 
important  bearing  on  the  subject,  for  peptic  ulcer  in  the  young  is  a 
more  acute  and  remediable  disease  than  is^peptic  ulcer  in  the  middle- 
aged.  Bear  in  mind  always  this  interesting  fact  that  in  3'oung  women 
of  the  chlorotic  type  (more  rarely  men)  one  expects  acute  ulcer.  In  men 
(more  rarely  women)  between  thirty  and  fifty  one  expects  cnronic 
ulcer.  The  acute  ulcers  are  curable  b}"  simple  measures,  as  a  rule. 
The  chronic  ulcers  call  often  for  surgical  intervention,  though  both 
of  these  statements  are  subject  to  exceptions. 

A  majority  of  peptic  ulcers  are  found  in  the  pj^loric  portion  of  the 
st_omach  and  the  first  three  inches  of  the  duodenum;  and  such  loca- 
tions have  an  important  bearing  upon  the  complications  which  may 
ensue,  as  well  as  upon  the  nature  of  surgical  treatment. 

Three  varieties  of  peptic  ulcer  are  described:  (1)  The  acute  round 
ulcer,  punched  out,  as  it  were;  (2)  the  irregular  burrowing,  chronic 
9 


130 


THE    ABDOMEN 


ulcer,  which  may  involve  large  areas  of  the  stomach;    (3)  erosions  of 
the  mucosa. 

The  acute  round  ulcer  may  run  into  the  chronic  form,  or  it  may 
progress  rapidly  to  perforation.  Most  commonly  it  heals  spontane- 
ously. It  may  gi\e  rise  to  hcmorrluujc  or  it  may  V)e  associated  with 
little  or  no  hemorrhage.  Often  it  causes  boring,  loj-alized  ^viin  and 
tenderness;  occasionally  there  is  no  pain.  In  more  than  90  per  cent, 
of  the  cases  it  clauses  'Vomiting;  In  nearly  80  per  cent,  of  the  cases  the 
vomitus  is  bloody. 

Chronic  ulcer  ma}'  be  developed  out  of  acute  idcer,  and  its  course  may 
run  over  years.  If  it  has  attacked  the  nuiscularis,  it  may  never  heal. 
It  causes  pain  in  nearly  Un  per  cent,  of  cases,  audit  cauacs  vomiting  more 

often  even.  The  bloody  vomit- 
ing of  chronic  ulcer  is  as  com- 
mon as  that  from  acute  ulcer, 
and  tenderness  in  the  ejjigas- 
trium  beneath  the  left  shoulder- 
blade,  or  about  the  tenth  left 
rib,  is  a  frequent  s3-mptom. 

Erosions  are  often  impossible 
to  distinguish  postmortem.  They 
are  slight  abrasions  of  the  mu- 
cosa, and  ma}''  be  single  or 
numerous.  Such  is  the  condi- 
tion described  as  "simple  ero- 
sions" by  Dieulafoy.  He  also 
described  a  form  to  which  he 
applied  the  term  "ex  ulceratio 
simplex,"  which  is  more  exten- 
sive than  the  simple  erosion, 
and  may  expose  .small  arterioles, 
giving  rise  to  excessive — even  to 
fatal  —  hemorrhages.  Erosions 
are  found  in  all  parts  of  the 
stomach. 

Peptic  ulcers  may  be  single 
or  multiple,  and  it  is  likely  that 
they   are    multiple    more   often 
than  generally  is   supposed.     A 
common  estimate  is  that  19  per  cent,  of  all  cases  show  multiple  ulcers. 
Ulcer  of  the  duodenum  may  be  associated  with  gastric  ulcer — the  pres- 
ence of  the  one  does  not  rule  out  the  other. 

The  course  of  peptic  ulcer  is  as  various  as  its  form.  Both  the  acute 
and  chronic  varieties  may  perforate;  both  may  set  up  extensive  perigas- 
tric inflammation ;  both  may  cause  adhesions  to  neighboring  organs.  The 
chronic  ulcer  leads  to  far  more  extensive  and  crippling  inflammation, 
perforation,  adhesions,  and  malformation  than  does  the  acute.  Ulcer 
on  the  posterior  surface  of  the  stomach  is  not  likely  to  cause  so  alarm- 


Fig.  62. — Chronic    gastric    ulcer    ("Warren 
Museum,  Harvard,  2199). 


PEPTIC    ULCER  131 

ing  a  form  of  perforation  as  is  anterior  ulcer,  for  adhesions  do  not  form 
so  readily  on  the  anterior  surface.  Perforation  may  give  rise  to  im- 
mecHate  outi^ouring  of  gastric  contents  and  to  a  general  peritonitis; 
or  through  adhesions  and  locaHzetl  abscess  a  more  chronic  form  of 
disease  may  be  established,  with  pockets  of  pus,  forming  most  commonly 
behind  the  stomach  in  the  lesser  cavity  of  the  peritoneum,  causing  sub- 
diaphragmatic abscess,  or,  in  rare  cases,  subphrenic  pyopneumothorax. 
Karcly  fistulie  form,  Avhich  may  connect  the  stomach  with  the  gall- 
bladder or  the  intestines,  or  may  penetrate  through  the  skin. 

Hemorrhage  from  peptic  ulcer  is  extremely  variable.  Four  varie- 
ties of  hemorrhage  are  described : 

(1)  Frecpent  slight  hemorrhage, — venous  or  cajDillary  oozing, — 
sapping  vitality,  leading  to  profound  anemia,  often  long  undetected — 
a  serious  matter. 

(2)  Intermittent  hemorrhage  of  considerable  quantity,  probably 
from  a  small  eroded  artery.  This  rarely  ends  with  fatal  bleeding, 
but  the  patient  becomes  profoundly  depressed. 

(3)  Acute  and  profuse  hemorrhage,  frequently  repeated.  It  may 
kiU  the  patient. 

(4)  An  overwhelming,  quickh'  fatal  hemorrhage,  due  to  the  erosion 
of  a  large  artery. 

The  reader  wiU  see  then  that  the  progress  of  peptic  ulcer  may  lead 
to  two  alarming  conditions, — perforation  and  hemorrhage, — while  the 
healing,  or  attempted  healing,  of  an  ulcer  may  lead  to  serious  rnechan- 
ical  distortion  or  crippling,  through  cicatrization.  The  important 
varieties  of  mechanical  crippling  are  pyloric  stenosis  and  hour-glass 
stomach. 

Pyloric  stenosis  is  an  affair  of  gradual  onset.  Generally,  it  does  not 
at  once  interfere  with  gastric  function  and  plug  back  or  delay  the  chyme, 
because  the  gastric  muscularis  undergoes  compensatory  hypertrophy 
arid  succeeds  for  a  time  in  overcoming  the  pyloric  obstruction.  In 
the  course  of  time,  however,  the  muscular  activity  of  the  stomach  fails 
to  respond  satisfactorih^,  so  that  the  gastric  tonus  is  lost,  when  a  thin- 
ning and  dilatation  of  the  stomach-wall  ensue.  These  pyloric  cica- 
trices ma}'  form  bunches  of  considerable  size.  They  may  appear  as 
mere  slight  encircling  bands,  or  as  indurated  masses  as  large  as  a  hen's 
egg,  and  palpable  through  the  abdominal  wall. 

Distoiiion  of  the  stomach,  or  hour-glass  stomach,  as  it  is  commonly 
called,  is  due  to  contracting  cicatrices,  furrowing  the  wall  of  the  stomach, 
and  throwing  that  organ  into  a  series  of  two  or  more  pouches. 

Ulcer  of  the  duodenum,  bears  a  close  resemblance  to  ulcer  of  the 
stomach;  but  being  situated  in  a  thin-w^alled  organ,  as  contrasted 
with  the  stomach,  it  is  more  serious  in  its  consequences,  though  its 
progress  is  not  always  obvious  to  the  patient.  In  proportion  to  its 
frequency,  duodenal  ulcer  perforates  more  often  than  does  gastric 
ulcer.  HemorrhageTFom  duodenal  ulcer  occurs  in  the  same  fashion  as 
hemorrhage  from  gastric  ulcer,  but  the  bleeding  is  somewhat  more  wont 
to   be    abundant  and   lona;    continued.     Duodenal  blood   generally   is 


132  THE    AHDOMKN' 

passed  off  through  tho  bowel;  rarely  it  enters  the  stomach.  Gastric 
blood  is  usualh'  vomited;   sometimes  it  is  passed  off  by  the  bowel. 

Symptoms. — The  symptoms  of  peptic  ulcer  will  suggest  themselves 
to  the  student  who  is  familiar  with  the  morbid  anatomy,  and  the 
symptoms  will  be  found  to  \'ary  with  every  case  stuilied.  A  few 
years  ago  students  were  taught  that  a  definite  train  of  symptoms  was 
necessary  for  the  diagnosis,  or  for  the  consideration  even,  of  peptic 
ulcer — pain,  tenderness,  "dyspepsia,"  and  coffee-ground  vomitus,  or 
melena.  Recent  experiences  of  surgeons  convince  us  that  ulcer  may 
exist  for  years  without  causing  such  classic  symptoms.  For  example: 
I  was  recently  consulted  by  a  physician  who  told  of  persistent  anorexia, 
with  occasional  voimiting,  for  ten  years.  There  was  no  pain;  there 
was  no  hemorrhage;  he  was  not  prostrated.  Occasionalh'  he  was 
troubled  by  a  sense  of  soreness  and  tenderness  on  pressure  below  the 
tip  of  the  xiphoid.  Convinced  that  he  was  the  victim  of  a  chronic 
inflammatory  process  which  might  lead  to  malignant  disease  in  later 
life,  he  asked  me  to  do  an  exploratory  operation.  I  found  an  hour- 
glass stomach,  surrounded  by  numerous  and  dense  adhesions.  No 
active  ulcer  was  present.  Gastroplasty  after  Finney's  method  com- 
pletely relieved  his  symptoms. 

What,  then,  are  the  symptoms  of  peptic  ulcer  with  its  sequela^,  or 
how  shall  we  make  a  diagnosis?  That  is  one  of  the  most  difficult 
problems  of  abdominal  surgery.  If  the  clas.sic  symptoms— pain,  vomit- 
ing, and  hemorrhage — be  present,  the  problem  is  easy;  but  I  believe 
that  in  many  cases  of  ''dyspepsia"  gastric  ulcer  or  its  complications 
is  present  without  many  or  all  the  classic  sjinptoms.  Carefully  con- 
ducted laboratory  tests  help  us  to  a  diagnosis.  In  the  presence  of 
peptic  ulcer  hydrochloric  acid  is  increased  generally.  Slight  traces  of 
blood  in  the  stomach  may  be  detected  b}-  the  guaiac  test.^  These 
investigations  may  be  made  by  the  use  of  the  stomach-tube,  and  the 
gastric  contents  must  be  expressed.  Vomited  gastric  contents  give 
a  much  less  satisfactory  test.  We  have  to  deal  with  a  s}Tnptom- 
complex.  Pain,  preceding  and  relieved  by  vomiting,  at  a  varying 
period  after  meals, — one  to  three  hours, — associated  with  excess  of  free 
hydrochloric  acid  and  blood  in  the  stomach,  makes  the  diagnosis  of  ulcer 
reasonably  sure. 

Tenderness  on  j:)ressure  in  the  epigastrium  is  a  frequent  symptom. 

In  the  case  of  an  old  ulcer  with  a  thickened  base  the  mass  may  some- 
times be  felt  in  the  pyloric  region. 

1  Guaiac  test:  Fresli  alcoholic  solution  of  guaiac  should  be  made  by  scraping 
with  a  knife  a  few  grains  of  gum  guaiac  into  a  test-tube  containing  aljout  5  cc.  of 
alcohol,  in  which  the  guaiac  (juickly  dissolves.  It  is  better  to  select  that  portion 
of  the  gum  guaiac  api)earing  as  yellow  nuggets  on  the  surface.  A  few  drojjs  of 
hydrogen  dioxid  are  added.  The  stomach-contents  or  the  waterj-  mixture  of  feces 
to  be  examined  are  mixed  in  a  test-tube  with  one-third  their  volume  of  glacial 
acetic  acid,  and  the  wiiole  shaken  with  an  equal  volume  of  ether.  On  standing, 
the  ethereal  extract  containing  the  hemoglobin,  if  present,  will  .sej)arate  and  occupy 
the  upper  portion  of  the  mixture  in  the  tube.  A  few  drops  of  this  ethereal  extract 
are  next  added  to  the  alcoholic  guaiac  solution,  and  if  blood  was  i)resent  in  the 
original  material,  a  blue-violet  color  sliould  appear  in  the  mixture.  So  delicate  is 
tills  test  that  meat  in  the  s-tomach-contents  will  give  the  blue  color. 


PEPTIC   ULCER  133 

The  general  s}-mptoms — loss  of  weight  and  anemia,  with  diminished 
total  amount  of  urine  excreted,  and  chronic  constipation — are  also 
suggestive. 

The  symptomatology  of  duodenal  ulcer  is  more  obscure  than  that 
of  gastric  ulcer,  and  the  two  are  often  indistinguishable.  In  duodenal 
ulcer,  however,  the  pain  may  be  more  to  the  right  of  the  middle  line, 
and  blood  must  be  looked  for  carefully  in  the  stools,  rather  than 
in  the  vomit  us.  There  may  be  no  vomiting.  The  blood  passed  by 
the  stools  may  be  in  minute  traces  only,  or  it  may  appear  in  large, 
tarry  masses. 

Perforation  occurs  in  about  6.5  per  cent,  of  all  cases  of  peptic  ulcer. 
The  symptoms  of  acute  perforation  are  overwhelming  pain  in  the  epi- 
gastrium, followed  by  a  general  or  localized  peritonitis.  The  acute 
pain  signifies  acute  perforation,  and  is  far  more  serious  than  the  chronic, 
slowly  progressing  perforations,  which  become  limited  by  adhesions 
to  surrounding  organs. 

Diagnosis. — The  diagnosis  of  peptic  ulcer  has  been  indicated  in  the 
foregoing  paragraphs.  One  looks  for  a  long  train  of  dyspeptic  sj^mptoms, 
gastralgic  attack:,  and  hemorrhage.  One  must  differentiate  these  ulcers 
from  disease  of  the  bile-passages,  from  pancreatitis,  from  gastritis,  peri- 
gastritis, gastralgia,  and  appendicitis,  with  all  of  which  conditions  peptic 
ulcer  may  be  associated,  and  from  which  it  cannot  alwaj-s  be  distin- 
guished. In  diseases  of  the  bile-passages  pain  is  more  constant  and  acute, 
is  longer  continued,  and  is  not  likely  to  be  associated  with  vomiting  on 
the  ingestion  of  food.  The  same  statement  is  true  of  pancreatic  disease. 
In  gastritis  pain  is  less  constant;  it  does  not  come  on  at  such  regular 
periods,  nor  is  it  so  commonly  associated  with  and  relieved  by  vomiting. 
Gastralgia  is  relieved  by  ingested  food.  A  chronic  appendicitis  may 
cause  obscure  gastric  sj-mptoms  suggesting  ulcer^s^-mptoms  of  "dys- 
pepsia," belching  of  gas,  and  distaste  for  food;  but  the  characteristic 
pain  and  vomiting  rareh"  are  present.  Acute  perforating  duodenal  ulcer 
pours  out  chyme  into  the  light  flank  and  appendix  region,  setting  up 
an  acute  peritonitis  throughout  that  area.  It  is  a  common  error  to 
mistake  perforating  duodenal  ulcer  for  acute  appendicitis. 

Prognosis. — The  prognosis  of  acute  ulcer  is  good,  generally,  if  rest 
and  dieting  be  observed.  The  prognosis  of  erosions  is  good  also,  with 
the  same  proviso;  but  the  prognosis  of  chronic  ulcer  is  not  so  favorable, 
and  the  statistics  of  the  Massachusetts  General  Hospital  show  that 
about  50  per  cent,  of  chronic  ulcers  are  either  not  cured  b}-  medical 
treatment  or  that,  if  sj-mptomatically  cured,  the}'  recur. 

Treatment  of  Peptic  Ulcer. — When  you  have  to  deal  with  a  patient 
the  subject  of  an  obscure  chronic  '' ch'spepsia "  which  has  withstood 
intelligent  medical  treatment  for  a  year  or  longer,  you  are  fairly  safe 
in  assuming  that  the  trouble  is  one  of  mechanical  damage,  and  that  a 
surgical  operation  on  one  or  more  of  five  organs  will  bring  relief — on 
the  stomach,  bile-passages,  pancreas,  kidney,  or  appendix. 

Every  case  of  peptic  ulcer  should  have  the  benefit  of  an  expert 
internist's  opinion  and  proper  intelligent  medical  treatment,  which,  in 


134 


THE    AHDOMEN 


general  terms,  consists  of  rest  and  cleanliness  for  the  organs  concerned. 
Rest  is  obtained  by  the  use  of  light  liquid  diet  or  rectal  feeding.  Clean- 
liness is  maintained  through  abstinence  from  food  and  by  gastric 
lavage. 

The  surgeon  also  in  his  treatment  aims  at  rest  and  cleanline.ss,  and 
attains  these  by  supplying  the  laboring  organs  with  additional  and 
competent  drainage — drainage  into  the  intestines  at  a  point  below  the 
pylorus.  Such  drainage  is  secured  through  the  operation  of  gastro- 
enterostomy or  through  Finney's  pyloroplasty. 

Methods  of  gastro-enterostomy  are  various.  Suffice  it  here  to  say 
that  two  general  methods  are  in  common  use — anterior  gastro-enter- 


Fig.  63. — Diagram    illustrating   anterior   gastro-entero.stomy. 
between  proximal  and  distal  coils  (Gould). 


Jej  unoj  oj  unostomy 


ostomy  and  posterior  gastro-enterostomy.  Anterior  gastro-enteros- 
tomy is  secured  by  bringing  up  a  loop  of  the  jejunum  in  front  of  the 
omentum  and  forming  an  anastomosis  between  it  and  the  stomach 
at  the  lowest  point  available  in  the  latter  organ — generally  near  the 
pyloric  area.  Posterior  gastro-enterostomy  is  preferable.  I  need  not 
here  go  into  a  discussion  of  the  long-loop  and  no-loop  operations,  and 
of  entero-enterostomy  with  or  without  division  of  the  afferent  loop. 
Excellent  present-day  opinion  favors  the  no-loop  operation  of  Mayo, 
by  which  an  anastomosis  is  made  between  the  lowest  portion  of  the 


PEPTIC    ULCER 


135 


stomach  and  the  jejunum,  where  it  Hos  behind  the  stomach,  three  or 
four  inches  from  the  end  of  the  duodenum  or  Hgament  of  Treitz.^ 

Finney's  operation  is  often  applicable  to  gastric  ulcer  when  it  can 
be  done  without  opening  into  the  ulcerated  area.  It  gives  admirable 
physiologic  drainage. 

The  after-treatment  of  these  cases  is  extremely  simple.  Generally, 
convalescence  begins  at  once.  With  the  cessation  of  ether  vomiting 
patients  may  be  given  water  by  the  mouth;  albumin-water  and  thin 


Fig.  64. — Posterior  piastro-enterostomy.  The  clamps  have  boon  ajipliod  about 
3  inches  distal  to  the  duodenojejunal  flexure.  The  blades  of  the  stomach  clamp 
have  been  placed  obliquely  (Moynihan),  while  the  handles  point  to  the  patient's 
right  shoulder  (Mayo,  Munro)  (from  Gould,  drawn  according  to  the  suggestions  from 
W.  J.  Mayo). 

soup  after  twenty-four  hours,  a  full  liquid  diet  after  forty-eight  hours, 
and  a  carefully  prescribed  full  solid  diet  by  the  seventh  day.  Con- 
valescence is  quick,  and  patients  may  be  up  and  about  in  the  second 
week. 

The  modus  operandi  of  the  cure  of  ulcer  by  these  operations  is  an 
interesting  problem,  the  probability  being  that  the  additional  drainage 

1 1  refer  the  reader  to  the  text-books  on  operative  surgery  for  details  of  these 
elaborate  stomach  operations,  especially  Moynihan's  Abdommal  Operations,  and 
Surgical  Aspects  of  Digestive  Disorders,  by  J.  G.  Mumford. 


136 


THE    AUDO.MEN 


Fig.  65. 


-Finney's  ga.stroduodeno.c:tomy.     Cross-section  of   pylorus  and  duodenum 
before  operation,  for  comparison  with  Fig.  70  (Goukl). 


Fig.  66. — Mobilization  of  tlie  second  portion  of  the  duodenum  (Finney).  Note 
vertical  peritoneal  incision  parallel  to  and  to  tlie  right  of  the  second  portion  of  the 
duodenum.  The  duodenum  is  being  shelled  out  with  the  finger.  Also  note  the 
dotted  line  on  the  edge  of  the  lesser  omentum.  A  superficial  cut  through  the  omen- 
tum at  this  point  allows  the  pylorus  to  drop  down,  thus  assisting  in  the  mobilization 
of  the  duodenum  (Gould). 

relieves  the  diseased  area  of  a  constant  irritation  and  allows  healing  to 
take  place  rapidly. 


Fig.  67. — Gould's  modification  of  Finney's  operation.  Note  application  of 
clamps.  On  the  stomach  they  are  placed  parallel  with  the  greater  curvature,  thus 
controlling  the  hemorrhage  from  the  vessels  which  are  seen  crossing  line  of  future 
incision.  Inner  jaws  of  both  clamps  touch  at  the  pyloric  angle.  When  the  handles 
are  brought  together,  the  pyloric  angle  (P)  is  put  on  the  stretch.  It  can  be  seen 
that  the  use  of  guides  is  unnecessary  to  make  the  folds  lie  side  by  side  (Gould). 


Fig.  68.— Gould's  modification  of  Finney's  operation.  Clamps  now  side  by 
side.  Folds  approximated  by  a  continuous  seromuscular  stitch.  Stomach  incision 
to  mucous  membrane;  duodenum  then  opened  freely  to  pyloric  angle.  Scissors 
now  cutting  out  redundant  mucous  membrane  at  dotted  line.  The  next  step  is  to 
sew  X  to  X,  beginning  at  the  pyloric  end  of  the  tongue  (Gould). 


138 


THE    ABDOMEN 


_^xs^u} 


Fig.  69. — Gould's  modification  of  Finney's  operation.  Tongue  now  closed  over 
by  continuous  stitch  wliich  has  turned  corner  to  finish  front  of  suture,  bringing  x  to 
x;  (T)  sewed  over  tongue.  The  line  of  suture  is  finally  buried  by  a  seromuscular 
stitch  (Gould). 


$to- 


Fig.  70. — Finney's  gastroduodenostomy.  Cross-section  after  operation,  show- 
ing increase  in  caliber  of  pylorus;  caliber  increased  over  Fig.  69  by  length  of  sewed 
edges  (Gould). 


I  cannot  recommend  excision  of  the  ulcer  as  a  routine  measure. 
Rarely,  it  may  be  deemed  necessary. 


PYLORIC   OBSTRUCTION 


139 


PYLORIC   OBSTRUCTION 

Pyloric  obstruction  is  one  of  the  most  important  complications  of 
ulcer.  It  is  due  commonly  to  cicatricial  contraction  of  ulcer  of  the 
p}'loric  portion,  as  I  have  explained  already,  and  the  obstruction  may 
be  very  slight  or  complete;  but  even  when  slight,  its  effect  upon  the 
stomach  and  the  stomach's  mechanism  is  marked  and  disastrous  in 
the  long  run.  There  are  other  causes  of  pyloric  stenosis,  such  as  neo- 
plasms— benign  and  malignant — pressure  from  without,  crippling 
extensive  adhesions,  and  the  dragging  of  a  prolapsed  stomach,  causing 
a  kink  at  the  pylorus.  Whatever  the  cause,  the  stomach  will  eventually 
become  thinned  and  distended.  If  it  contains  comfortably  more  than 
40  ounces  of  water,  it  may  be  regarded  as  a  dilated  stomach. 

Pyloric  obstruction  of  infancy  is  congenital  or  is  acquired  early. 


Fig.  71. — Operation  of  Roux  completed  (schematic). 

The  symptoms  of  pyloric  obstruction  are  properly  those  of  gastric 
dilatation.  An  uncomplicated  obstruction  rarely  gives  rise  to  symp- 
toms. Obstruction  with  dilatation  quickly  becomes  associated  with 
gastric  stasis — that  is  to  say,  ingested  food  remains  in  the  stomach 
longer  than  normal.  If  one  removes  with  the  stomach-tube  the  stomach- 
contents  eight  hours  after  the  patient  has  taken  a  full  meal,  one  should 
find  no  trace  of  food  if  the  stomach  be  normal.  Food  found  after 
eight  hours  signifies  delayed  motility  or  stasis,  and  the  symptoms  are 
due  to  this  stasis.  The  picture  is  a  complicated  and  distressing  one. 
The  patient  becomes  emaciated,  is  troubled  with  pain  coming^  on 
three  or  four  hours  after  eating,  has  more  or  less  vomiting,  the  vomitus 
varying  in  amount  according  to  its  frequency,  and  at  times— perhaps 
once  in  three  or  four  days  or  perhaps  very  rarely — he  vomits  enormous 


140 


THE    ABDOMEN 


quantities  of  food.  Ho  is  troubled  with  thirst,  constipation,  heart- 
burn, and  heiuhiche.  An  inijxjrtant  sifrn  is  visible  ijcristalsis.  Often  a 
distinct  splashing  is  heard  if  the  examiner  shakes  the  abdomen  with  his 
hand.  The  urine  is  scanty,  the  tongue  dry  and  parched,  and  the  urgency 
of  the  condition  may  vary  all  the  way  from  a  state  of  mild  "dyspepsia" 
up  to  impending  death  fi'om  starvation. 

The  treatment  of  ])yloric  obstruction  should  be  operative  in  the 
case  of  persons  able  to  submit  to  operation  and  desirous  of  regaining 
permanent  health.  On  the  other  hand,  palliative  treatment  only  may 
be  pcrmissil3le,  and  palliative  treatment  often  relieves  and  seems  at 
times  to  cure.  Palliative  treatment  consists  in  lavage  of  the  stomach, 
careful  feeding,   and  the  prescribing  of  tonics   and   laxatives.      Un- 


Fig.  72. — Roux's  operation  complete  (Moynihan). 

fortunately  for  the  outlook  of  patients  who  depend  on  palliative  treat- 
ment, we  cannot  prevent  the  frequent  implantation  of  cancer  upon 
the  site  of  an  old  ulcer,  whether  healed  or  unhealed.  My  recent  studies 
in  the  after-history  of  these  cases  at  the  Massachusetts  General  Hospital 
has  shown  that  a  majority  of  persons  with  stomach  dilatation,  when 
untreated,  die  within  a  few  years ;  that  a  small  percentage  are  relieved, 
and  that  a  still  smaller  percentage  (12  per  cent.)  recover. 

Surgical  treatment  of  pyloric  stenosis  is  by  gastro-enterostomy.  by 
Finney's  pyloroplasty,  or  by  pylorectomy.  Gastro-enterostomy  is  best 
performed  by  the  no-loop  method,  and  is  generally  satisfactory.  How- 
ever, in  the  case  of  a  greatly  dilated  stomach  the  new  stoma  may  be 
dragged  upon  as  the  stomach  retracts,  so  that  one  may  sometimes 


HEMORRHAGE  141 

prefer  to  do  the  operation  of  Chaput  or  that  of  Roux,  as  shown  in  the 
accompanying  cuts.  If  the  stomach  and  duodenum  are  not  too  much 
tied  down  and  buried  in  adhesions,  Finney's  operation  is  extremely 
satisfactory.  In  any  case  of  doubt  as  to  the  nature  of  the  obstruction, 
especially  when  a  considerable  indurated  mass  is  felt,  one  should  suspect 
malignant  disease  and  should  perform  pylorectomy.  For  congenital 
or  infantile  pyloric  stenosis  gastro-enterostomy  is  the  only  cure.' 

The  after-history  of  these  obstruction  cases,  when  treated  by  ap- 
propriate operation,  is  exceedingly  satisfactory,  but  I  cannot  too 
earnestly  caution  the  student  and  practitioner  against  indiscriminate 
and  routine  operating.  Every  case  should  be  treated  on  its  own  merits 
and  according  to  the  nature  of  the  mechanical  derangement,  otherv\dse 
the  practitioner  may  be  distressed  to  find  that  his  patient  is  not  benefited 
and  that  the  old  symptoms  return  after  a  short  time.  In  no  class  of 
cases  more  than  in  stomach  disorders  is  a  careful  and  thorough  study 
of  conditions  demanded,  and  no  man  should  presume  to  take  up  this 
line  of  work  unless  he  has  attended  the  surgical  clinic  of  an  expert  and 
has  practised  the  operations  upon  the  cadaver  or  upon  living  animals. 

HEMORRHAGE 

Hemorrhage  from  peptic  ulcers  may  be  demonstrated  by  finding 
stomach  blood — vomited  or  expressed — or  blood  in  the  stools.  There 
are  numerous  causes  for  gastric  hemorrhage  besides  gastric  disease; 
among  such  causes  are  diseases  creating  venous  stasis,  such  as  cardiac, 
renal,  and  hepatic  disorders,  as  well  as  rare  cases  of  angioneurotic 
edema  and  aneurysm.  But  it  is  gastric  disease  with  which  we  are  now 
dealing — with  gastric  ulcer  and  gastric  cancer.  I  have  spoken  of  the 
varieties  of  bleeding  from  gastric  ulcer.  There  is  the  bleeding  from 
acute  ulcer  and  from  chronic  ulcer.  Hemorrhage  from  acute  ulcer 
rarely  is  persistent  or  extremely  grave,  though  there  are  exceptions  to 
this  rule.  Hemorrhage  from  chronic  ulcer  may  be  slight  or  over- 
whelming. The  phrase  "acute  bleeding  ulcer"  is  used,  but  it  is  a  mis- 
leading phrase,  since  it  seems  to  imply  active  hemorrhage  from  an  acute 
ulcer,  whereas  the  condition  is  more  frequently  found  to  be  an  active 
hemorrhage  from  a  chronic  ulcer.  When  the  first  evidence  of  ulcer  is  a 
sudden  hemorrhage,  however,  the  chances  are  that  the  ulcer  is  acute. 
The  Massachusetts  General  Hospital  records  show  a  total  mortality  from 
stomach  hemorrhage  of  3.7  percent. — males,  17  per  cent.,  females,  1.27 
per  cent.  Moreover,  it  appears  that  lethal  hemorrhage  is  much  less 
common  in  the  young  than  in  the  middle  aged,  and  less  fatal  in  acute 
ulcer  than  in  chronic  ulcer.  This  3.7  per  cent,  is  a  low"  mortality  from 
hemorrhage.     Other  statistics  give  the  death-rate  as  8  per  cent. 

The  treatment  of  hemorrhage  is  an  intricate  and  interesting  ques- 
tion.     In  general  terms  it   is  fair  to  assume  that  acute  ulcer  hemor- 

1  C.  L.  Scudder,  Boston  Med.  and  Surg.  Jour.,  1907,  vol.  clvii,  p.  321;  and  1909, 
vol  clx,  p.  273.  George  Thompson,  Surg.,  Gyn.,  and  Obs.,  1906,  vol.  iii,  p.  521. 
F.  E.  Bunts,  Surg.,  Gyn.,  and  Obs.,  1908,  vol.  vi,  p.  663. 


142  THE    AIJDOMEV 

rhage  may  be  subdued  by  rest  and  rectal  feeding,  while  chronic  ulcer 
hemorrhage,  though  it  may  be  allayed  for  a  time,  is  likely  to  recur  after 
such  internal  treatment,  and,  therefore,  recjuires  a  surgical  operation 
for  its  permanent  cure.  Moreover,  in  those  rare  eases  of  hemorrhage 
which  is  persistent  and  brings  the  patient  to  a  low  ebb,  an  operation 
must  be  done  immetliately  to  save  life. 

The  surgical  treatment  of  hemorrhage  from  gastric  ulcer  is  gastro- 
enterostomy. Other  methods  have  been  tried,  but  rareh-  have  proved 
successful.  Excision  of  the  ulcer  or  ligation  of  the  bleeding  point  is 
not  to  be  recommended  as  routine.  Time  is  lost  by  such  measures, 
and  the  bleeding  vessel  is  not  always  found.  Gastro-enterostomy, 
by  one  of  the  methods  already  described,  is  quick  and  reasonabl}'  safe. 
The  ulcer  is  put  at  rest,  the  bleeding  ceases  shortly,  and  convalescence 
generally  is  assured.  Some  care  in  feeding  is  required  aftei-ward,  and' 
if  the  patient's  strength  will  permit,  nutrient  enemata  will  be  employed 
for  five  or  six  days.     The  same  rules  apply  to  bleeding  duodenal  ulcer. 

PERFORATION 

Perforating  peptic  ulcer,  whether  acute  or  chronic,  must  be  treated 
surgically.  Though  spontaneous  cures  are  recorded,  the}'  are  too  rare 
to  be  anticipated  in  any  given  case. 

The  symptoms  of  acute  perforation  are:  sudden  pain,  acute  localized 
tenderness,  a  falling  and,  later,  a  rising  temperature,  a  rapid  and  com- 
pressible pulse,  peritoneal  facies,  and  vomiting  generally.  In  other 
words,  the  symptoms  are  quite  similar  to  those  of  perforative  appendi- 
citis, except  that  the  pain  and  tenderness  are  commonly  located  in 
another  region.  These  cases,  if  untreated,  go  on  to  a  diffuse  peritonitis 
which  kills  the  patient. 

The  treatment  is  by  early  operation.  Recoveries  are  rare  after 
eight  hours  have  passed  wdthout  such  treatment.  Open  the  abdomen 
through  the  right  rectus  muscle,  above  the  umbilicus.  Find  the  per- 
foration, and  sew  it  up  with  Lembert  stitches.  Wash  out  thoroughly 
the  abdomen  with  salt  solution,  and  drain  the  wound  with  gauze. 
The  ulcer  will  heal  usually  if  death  from  peritonitis  does  not  supervene. 
In  the  after-treatment  the  semirecumbent  position  aids  drainage, 
which  should  be  supplemented  further  by  a  proper  wick  passed  into 
the  pelvis  through  a  suprapubic  stab-wound. 

DISTORTION  OF  THE   STOMACH 

Distortion  of  the  stomach  (hour-glass  stomach)  may  be  regarded 
as  an  analogue  of  pyloric  stenosis.  In  other  words,  the  conditions 
which  cause  pyloric  stenosis  may  exist  elsewhere  in  the  stomach  and 
may  narrow  its  lumen.  There  may  be  one  or  more  constricting  cica- 
trices, so  that  the  stomach  is  thrown  into  two  or  more  pouches. 

Until  recently  it  was  beheved  that  many  cases  of  hour-glass  stomach 
were  congenital.  Further  study  convinces  us  that  congenital  hour- 
glass stomach  is  rare,  if,  indeed,  it  exists  at  all.     Most  of  the  cases 


GAS'];HIC   ADHESIONS  143 

investigated  show  that  the  deformity  is  due  to  cicatrices  following  an 
ulcerative  process. 

The  symptoms  are  prolonged  ''dyspepsia,"  pain  and  tenderness, 
pain  relieved  by  vomiting  and  malnutrition,  frequently  associated  with 
pronounced  nervous  symptoms. 

The  diagnosis  is  difhcult.  Sundry  maneuvers  are  advocated  for 
demonstrating  and  making  prominent  the  various  pouches.  Wash  out 
the  stomach  until  the  water  returns  clear.  If  a  gush  of  foul  fluid  follows 
later,  it  comes  from  a  probable  second  pouch.  Another  test  advocated 
by  Moynihan  is  to  map  out  the  stomach  resonance  and  then  give  a 
Seidlitz  powder  in  two  portions;  after  twenty  or  thirty  seconds  an 
enormous  increase  of  resonance  will  be  found  in  the  upper  pouch  of  the 
stomach.  Later,  the  lower  pouch  will  become  distended.  In  spite 
of  such  ingenious  tests,  hour-glass  stomach  is  often  overlooked  until  it  is 
revealed  by  operation  or  at  autopsy. 

The  treatment  for  hour-glass  stomach,  hke  the  treatment  of  pyloric 
stenosis,  is  palliative  or  operative.  We  need  not  consider  palliation 
here.  Operation  generally  cures.  There  are  two  excellent  methods. 
If  the  cicatricial  tissue  be  not  too  abundant,  a  gastrogastrostomy  may  be 
done  by  Finney's  method,  or  by  overlapping  and  forming  an  anastomosis 
between  pouches.  In  other  cases,  where  the  distortion  and  surround- 
ing adhesions  are  extensive,  gastro-enterostomy  may  be  necessar}',  and 
in  such  case  the  surgeon  must  form  an  anastomosis  between  the  jejunum 
and  each  stomach  pouch. 

GASTRIC  ADHESIONS 

Gastric  adhesions  are  a  frequent  complication  of  gastric  ulcer. 
They  are  present  in  nearty  40  per  cent,  of  all  ulcer  cases,  and  are  a 
common  cause  of  distressing  symptoms.  They  distort  the  stomach; 
they  fix  it  in  abnormal  positions;  they  delay  its  motility,  and  they 
interfere  with  the  action  of  neighboring  organs.  Frequently  they  are 
accompanied  by  suppuration  and  burrowing  fistulse. 

The}^  are  due  to  the  extension  of  inflammation  from  gastric  ulcer, — 
the  most  serious  forms  of  adhesions, — or  to  a  peritonitis  spreading  to 
the  epigastrium  from  elsewhere  in  the  abdomen — perhaps  from  the 
appendix  or  Fallopian  tube.  An  inflamed  gall-bladder  may  become 
adherent  to  the  stomach  and  a  gastrocystic  fistula  form.  In  like  manner 
fistulse  may  connect  the  stomach  with  the  transverse  colon,  the  duo- 
denum, or  the  pancreas. 

The  sjrmptoms  of  gastric  adhesions,  or  perigastritis,  are  as  manifold 
as  are  the  pathologic  conditions,  and  the  symptoms  are  extremely 
puzzling.  Nearlj^  alwaj^s  there  are  ''dj'spepsia,"  indefinite  pain,  and 
occasional  vomiting.  The  chemic  output  of  the  stomach  may  be 
interfered  mth,  and  digestion  may  be  long  delayed.  Sometimes  bile 
is  vomited;  sometimes  there  are  recurring  attacks  of  intense  colic. 

The  surgical  treatment  of  gastric  adhesions,  granted  the  patient 
comes  to  surgery,  is  often  difficult.     If  the  adhesions  are  light  and 


144  THE   ABDOMEN 

easily  broken  down,  permanent  relief  may  follow  their  separation. 
On  the  other  hand,  if  heavy  bands,  with  fistula'  and  involvement  of 
other  organs,  exist,  the  best  treatment  is  gastro-enterostomy  to  facilitate 
stomach  drainage. 

GASTRIC  TETANY 

Gastric  tetany  is  occasionally  seen,  but  is  more  often  overlooked. 
In  every  case  of  tetany  one  should  think  of  the  possibility  of  pyloric 
obstruction.  Gastric  irritation  is  a  common  cause  of  convulsions  in 
children;  it  may  cause  convulsions  in  adults,  and  such  tetany  is  some- 
times associated  with  pyloric  stenosis.  The  spasms  are  due  probably 
to  the  absorption  of  some  poison  from  the  dilated  stomach,  with  an 
associated  painful  contraction  of  the  pylorus. 

The  treatment  is  directed  at  first  toward  relief  of  the  stomach  by 
lavage  or  induced  vomiting.  Often  lavage  is  difficult  or  impossible 
because  the  attempt  to  pass  a  stomach-tube  excites  renewed  spasms. 
Permanent  cure  may  be  obtained  by  Finney's  operation  or  by  gastro- 
enterostomy. 

GASTRIC  CIRRHOSIS 

Gastric  cirrhosis  deserves  mention,  though  it  is  a  rare  condition. 
The  disease  is  chronic,  and  does  not  appear  to  be  associated  with  ulcer 
or  cancer.  The  stomach-wall  is  found  thickened,  often  seared  and 
stenosed,  and  the  symptoms  resemble  those  of  long-standing  ulcer, 
except  that  the  vomiting  is  small  in  amount.  Patients  die  of  the 
disease  unless  reheved  by  operation.  Gastro-enterostomy  has  improved 
the  condition,  though  the  reason  for  such  improvement  is  not  im- 
mediately apparent. 

SPASM  OF  THE  PYLORUS 

Spasm  of  the  pjdorus  (Reichmann's  disease)  is  a  rare  condition, 
unassociatcd  with  obvious  pathologic  changes.  It  is  said  to  be  due  to 
gastric  hyperchlorhydria.  Often  it  will  be  relieved  by  lavage  and 
dieting.  Should  these  fail,  Finney's  operation  is  a  rational  method  of 
cure. 

GASTROPTOSIS 

Gastroptosis,  or  dislocation  downward  of  the  stomach,  is  commonly 
associated  with  dislocation  of  the  colon  and  right  kidney.  The  pro- 
lapsed stomach  is  often  dilated  also,  since  dragging  on  the  fixed  pylorus 
kinks  and  narrows  the  gastric  outlet.  The  greater  curvature  may  be 
found  on  a  level  with  the  navel,  or  as  low  as  the  pubes  even,  and  the 
diagnosis  of  ptosis  is  confirmed  by  dilating  the  stomach  with  air  or 
water,  and  finding  its  upper  border  low  in  the  epigastrium.  In  such 
case  the  pulsation  of  the  aorta  may  be  felt  easily  in  the  epigastrium. 

In  addition  to  such  general  treatment  as  I  shall  describe  when  deal- 
ing with  visceral  ptosis  as  a  whole  one  may  practise  a  variety  of  surgi- 
cal procedures  for  the  prolapsed  stomach.     I  have  been  satisfied  in 


CANCER  145 

two  cases  with  Bcyca's  operation  of  reefin<^  the  gastrohepatic  omentum, 
while  an  independent  or  supi)lementar3'  gastro-enterostomy  is  of  value 
also.  In  two  other  cases  of  gastroptosis  with  dilatation  1  have  found 
Finney's  pyloroplasty  to  relieve  the  symptoms. 

STENOSIS   OF   THE   PYLORUS 

Hypertrophic  stenosis  of  the  pjdorus  is  a  condition  occasionally  seen 
at  autopsy  and  upon  the  operating  table.  It  is  associated  with  gas- 
trectasis,  but  there  is  no  connective-tissue  development.  Micro- 
scopically, the  condition  is  found  to  be  hypertrophy  of  the  muscularis 
and  submucosa  of  the  pylorus.  It  has  been  suggested  that  some  of 
these  cases  may  be  congenital,  as  the  same  condition  is  found  also  in 
infants. 

Treatment  is  by  Finney's  operation  or  by  gastro-enterostomy. 

FOREIGN  BODIES 

Foreign  bodies  may  pass  through  the  esophagus  and  lodge  in  the 
stomach,  though  commonly,  if  they  pass  the  cardia,  they  escape  through 
the  pylorus.  The  victims  of  this  accident  are  generally  children,  insane 
persons,  or  drunkards.  One  sees  lodged  in  the  stomach  such  articles 
as  pins,  safety-pins,  shot,  coins,  plates  of  false  teeth,  hat-pins,  pebbles, 
masses  of  hair,  nails,  screws,  pieces  of  broken  glass,  etc.  In  the  case  of 
a  juggler,  I  have  seen  incredible  numbers  of  metallic  objects  removed 
from  the  stomach.  Dr.  T.  F.  Harrington,  of  Boston,  tells  me  that  he 
saw  a  soldier,  returned  from  the  Spanish  War,  who  was  treated  for 
sundry  wasting  diseases  without  avail;  at  the  end,  in  a  fatal  and  only 
hemorrhage,  the  man  vomited  a  hzard.  If  the  foreign  bodies  do  not 
pass,  they  may  remain  indefinitely  in  the  stomach  or  may  give  rise 
to  pain,  vomiting,  and  other  "  dyspeptic  "  symptoms.  They  may  cause 
ulcer;  they  may  perforate  the  stomach.  Most  of  these  objects  may  be 
encouraged  to  pass  on  with  the  fecal  stream,  but  cathartics  should 
never  be  employed.  Our  endeavor  is  to  incrust  the  foreign  bodj'  with 
some  non-irritating  food,  so  as  to  prevent  its  perforating  the  viscera 
or  doing  other  damage.  Give  a  diet  of  bread  and  milk  or  Indian-meal 
mush,  or  mashed  potatoes,  for  several  days,  and  follow  this  with  a  mild 
laxative.  In  rare  cases',  W'hen  there  has  been  long-standing  retention 
of  the  foreign  body  or  evidence  of  perforation,  one  must  operate. 
Not  long  ago  I  saw  a  colleague  cut  down  upon  a  stomach  from  which 
an  eight-inch  hat-pin  protruded  and  penetrated  the  liver.  The  head 
of  the  hat-pin  prevented  the  pin's  complete  exit  from  the  stomach. 

CANCER 

Cancer,  next  to  ulcer,  is  the  cUsease  of  the  stomach  which  interests 
us  most.  Gastric  cancer  is  extremely  common.  According  to  the 
figures  of  von  MikuHcz  and  Mayo,  one-third  of  all  cancers  are  found 
in  the  stomach.     We  were  formerly  told  that  it  is  a  disease  of  sudden 

10 


146 


THE    AH DOMEX 


onset,  coming  on  often  in  persons  of  previously  good  health  and  strong 
digestion.  On  the  contrary,  we  believe  to-day  that  cancel-  frecpiently 
develops  at  the  end  of  a  long  course  of  "dyspepsia,"  Ijeing  inii)lanted 
upon  ulcer  or  the  sequela?  of  ulcer.  Competent  writers  go  so  far  as  to  say 
that  00  per  cent,  of  all  cases  of  gastric  carcinoma  may  be  traced  to  pre- 
existing ulcer.  Cancer  of  the  stomach  is  nearly  always  primary,  those 
gastric  ulcers  which  are  secondary  being  traceable  usually  to  primar}' 
esophageal  cancer.  Metastases  from  gastric  cancer  are  fouud  in  the 
lymph-nodes,  along  the  lesser  curvature,  in  the  live)-,  in  the  pancreas, 


Fig.  73. — Lymphatics  of  tiie  stomach. 


and  in  other  more  distant  organs.  Bear  in  mind  that  enlarged  nodes 
along  the  greater  curvature  suggest  pjdoric  ulcer,  while  enlarged  nodes 
along  the  lesser  curvature  suggest  pyloric  cancer.  The  location  of 
cancer  in  the  stomach  is  in  the  pyloric  region  in  about  70  per  cent,  of 
the  cases;  on  the  posterior  surface  in  about  4  per  cent.;  cardia,  9 
per  cent.;  greater  curvature,  4  per  cent.;  anterior  surface.  3  per  cent.; 
fundus,  10  per  cent.  The  ratio  of  men  to  women  is  about  as  7  is  to  5. 
The  common  varieties  of  gastric  cancer  are  the  cylindric-celled 
adenocarcinoma  and  the  encephaloid  or  medullary  carcinoma;  next 
in  frequency  is  scirrhus,  and  then  colloid  cancer. 


CANCER  147 

Marked  gastric  changes  take  place  in  the  presence  of  cancer,  depend- 
ing upon  the  location  of  the  disease.  When  the  cancer  is  at  the  pylorus, 
it  causes  a  thickening  of  the  stomach-wall  in  the  pyloric  region  and  a 
gradual  closing  of  the  outlet,  associated  first  with  hypertrophy  of  the 
fundus  and  then  with  its  dilatation.  When  the  cancer  is  not  at  the 
pylorus,  it  may  involve  considerable  areas  of  the  gastric  wall  and  cause 
marked  deformity  and  crippling  of  the  organ,  with  frequent  adhesions 
to  the  neighboring  structures  and  direct  extension  of  the  disease  to 
those  structures.  Perforation  into  the  peritoneal  cavity,  followed  by 
a  diffuse  peritonitis,  is  a  not  infrequent  occurrence. 

In  regard  to  metastases,  remember  that  in  from  4  to  10  per  cent, 
of  the  cases  no  metastasis  has  been  found,  the  enlarged  nodes  present 
being  shown  to  be  hyperplastic  merely;  that  the  fundus  is  rarely  the 
seat  of  carcinoma,  and  that  its  lymphatic  nodes  seldom  are  involved. 
The  symptoms  of  gastric  cancer  are  either  latent  or  pronounced. 
In  a  great  many  cases  we  hear  a  story  of  long-continued  "dyspepsia" 
merely,  with  a  certain  amount  of  heartburn,  distaste  for  food,  especially 
for  meat,  and  sometimes  a  craving  for  highly  spiced  food.  Such  symp- 
toms may  exist  for  many  months  without  exciting  the  patient's  suspi- 
cions. There  is  generally  an  associated  loss  of  weight  and  strength, 
with  anemia,  and  possibly  an  irregular  temperature,  with  occasional 
chills.  In  a  certain  proportion  of  cases  free  hydrochloric  acid  is  de- 
creased or  lacking  in  the  stomach-contents,  while  lactic  acid  and  putre- 
factive organisms  are  found;  blood  in  abundance  or  in  mere  traces 
may  be  present,  and  late  in  the  disease  the  Oppler-Boas  bacillus  (a  club- 
shaped  organism).  Indican  is  often  increased  in  the  urine,  and  in  about 
one-third  of  the  cases  there  is  albuminuria  with  casts.  Frequently  there 
is  edema  of  the  feet  and  legs  and  of  the  abdominal  wall  even.  The 
bowels  are  nearly  always  constipated. 

In  marked  cases  pain,  hemorrhage,  and  vomiting  are  the  impor- 
tant symptoms,  though  all  these  symptoms  may  be  absent  throughout 
the  disease.  .     . 

The  diagnosis  of  cancer  of  the  stomach  is  extremely  difficult  m  its 
early  stages.  But,  given  a  patient  of  middle  age,  with  prolonged 
"dyspepsia,"  distaste  for  food,  occasional  attacks  of  epigastric  pam, 
and  wasting,  one  should  suspect  cancer.  If  to  these  symptoms  bloody 
vomiting  be  added,  and  if  a  mass  can  be  felt  in  the  epigastrium,  the 
diagnosis  of  cancer  is  almost  assured.  But  we  must  not  wait  for  these 
late  manifestations  in  order  to  confirm  the  diagnosis.  If  we  are^  m 
doubt,  and  if  the  patient's  strength  will  permit,  a  rapid  exploration 
should  be  undertaken  early  to  ascertain  the  exact  condition. 

Treatment.— Cancer  of  the  stomach  is  a  surgical  disease,  as  is 
cancer  elsewhere.  No  so-called  medical  treatment  avails  for  a  cure. 
It  may  well  be  that  the  patient  and  his  friends  prefer  mild  measures 
and  a  waiting  for  death.  That  is  at  their  own  discretion.  There  can 
be  no  doubt  that  cases  of  advanced  cancer  are  incurable  by  surgery, 
and  the  kinder  course  is  palliation,  but  accumulating  experience  shows 
that  in  the  early  stages  of  gastric  cancer,  extirpation  of  the  chsease,  by 


148 


THK    AHDO.MKX 


a  t'omj)ot(Mit  surucon,  will  cure  a  jioodly  propoilioii  of  })ati('iits,  or, 
more  often,  will  post])onc  for  years  the  inevitable  eml.  It  was  formerly 
said  that  the  fin(lin.i>;  of  a  tumor  eontraindicated  gastrectomy.  On 
the  conti-ai-y,  the  finding  of  a  tumor  may  be  cause  for  hope  from  gas- 
trectomy. A  small  tumor  of  the  anterior  j^yloric  region  ma}'  be  felt 
and  excised  and  the  patient  recovei',  while  a  large  and  extensi\'e  growth 
on  the  posterior  wall  of  the  stomach  may  run  its  course,  without  detec- 
tion, to  a  fatal  termination. 

Should  the  patient  elect  to  have  no  operation  done,  wv  must  strive 
to  make  him  comfoitable  with  gasti-ic  lavagx;;  with  small  and  fre(|uent 
feedings  of  easily  chgested  food,  es]jecially  milk;  with  gradually  ascend- 


Fig.  74. — Sliowing  ligation  of  gastrohepatic  omentum  and  superior  vessels  in 
such  manner  as  to  leave  all  the  lyni})h-nodes  attached  to  the  part  of  the  stomach 
to  be  excised;  also  lines  of  division  of  duodenum  and  stomach  (after  ^^'.  J.  Mayo, 
Ann.  Surg.). 

ing  doses  of  the  compound  tincture  of  iodin  (beginning  with  5  minims) ; 
with  morphin  for  pain;  and  with  other  remedies  to  meet  the  conditions 
which  arise.  The  symptoms  vary  with  the  location  of  the  disease. 
Cancer  of  the  fundus  may  cause  no  symptoms  other  than  anorexia, 
wasting,  and  debility;  cancer  of  the  pylorus  may  cause  the  most  dis- 
tressing symptoms — intolerable  pain,  vomiting,  and  constitutional 
exhaustion  leading  to  early  death.  In  such  cases  the  physician  is 
driven  to  the  constant  use  of  morphin. 

There  are  operations  other  than  gastrectomy  for  cancer  of  the 
stomach.  There  are  radical  operations  and  palhative  operations,  and 
the  choice  depends  upon  the  site  and  extent  of  the  disease.  We  excise 
cancer  of  the  stomach  when  the  growth  is  small,  the  lymphatic  connec- 


CANCER 


149 


tions  but  slightly  involved,  and  when  no  metastasis  exists.  We  perform 
palliative  operations  to  relieve  impending  starvation,  and  for  pain  and 
vomiting.  The  radical  operations  are  pylorectomy,  partial  gastrectomy, 
and  total  gastrectomy;  and  the  difficulties  of  these  operations  are  in 
the  same  order.  Practically,  however,  a  mere  pylorectomy  is  of  little 
service  in  cancer,  because  it  is  not  radical  enough.  Partial  gastrectomy 
is  the  more  common  and  satisfactory  operation.  The  mortality  varies 
between  8  and  50  per  cent.,  but  as  we  are  getting  these  cancer  cases 
earlier,  we  are  securing  a  lower  operative  mortality  and  an  increasing 
number  of  permanent  cures.  The  accompanying  cuts  (Figs.  74-77) 
illustrate  the  operation  which  I  have  been  using.  It  is  the  operation 
described  and  advocated  by  W.  J,  Mayo  in  1904. 


Fig.  75. — Showing  methods  of  excision.     Note  that  all  the  glands  in  the  greater 
curvature  are  removed  in  every  case  (after  W.  J.  Mayo,  Ann.  Surg.). 

Open  the  abdomen  through  the  right  rectus  muscle,  and  turn  out 
the  stomach  and  omentum.  Tie  off  the  gastrohepatic  omentum  close 
to  the  liver,  thus  opening  widely  the  lesser  omental  cavity  and  mobiliz- 
ing the  pylorus.  Pack  off  with  gauze  the  entire  area  exposed.  Then  tie 
the  four  important  arteries,  two  above  the  stomach  and  two  below  it. 
The  gastric  artery  is  best  secured  at  once  by  double  ligature  where  it 
joins  the  lesser  curvature,  about  an  inch  below  the  cardia.  The  superior 
pyloric  artery,  a  branch  of  the  hepatic,  is  tied  just  above  the  pylorus. 
To  get  at  the  tv/o  lower  vessels,  pass  the  left  hand  into  the  lesser  cavity 
behind  the  pylorus,  find  the  gastrocolic  omentum,  and  raise  it  from 
the  transverse  mesocolon;   then  isolate  and  secure  from  the  front  the 


loU 


THK    AHDO.MKX 


right  gastro-epiploie  artery.  Next  tie  the  loft  p;astro-o])ij)loif'  artory 
at  a  suitable  point  on  the  greater  curvature,  and  tic  in  sections  and  cut 
away  the  gastrocolic  omentum,  taking  great  care  not  to  interfei'e  with 
the  middle  colic  arter}',  which  runs  in  the  transverse  mesocolon. 

It  is  a  simple  matter  now  to  remove  a  ])orti(jn  of  the  st(jmach: 
double  clamp  the  (.luodenum,  and  divide  it  with  the  cautery  bcjtween 
the  clamps.  Then  turn  in  the  distal  stump  of  duodenum.  Cut  off  the 
superior  portion  of  the  stomach  in  much  the  same  fashion,  thus:  gi'asp 
the  viscus  with  a  rubl^er-guarded  holding  clamp,  and  about  half  an 
inch  below  it  j)lace  a  strong  ])iting-clamp,  to  prevent  leakage.  Then 
cut  off  with  the  cautery  the  stomach  between  the  two  clamps  and  turn 


Fig.  76. — Showing  closure  of  cut  duodenal  end  by  circular  suture,  and  first  row  of 
sutures  being  j)Iaced  on  the  stomach  side  (after  W.  J.  Mayo,  Ann.  Surg.i. 

in  the  gastric  stump.  We  have  now  an  isolated  stomach  pouch  and 
an  isolated  intestine  to  be  connected.  Various  methods  of  making 
this  connection  have  been  devised.  The  so-called  Billroth's  first  method 
consists  in  uniting  the  stump  of  duodenum  with  the  lower  angle  of  the 
gastric  stump,  but  this  method  forms  an  insecure  joint  and  is  now  little 
used.  Kocher  inserts  the  duodenal  stump  into  the  posterior  wall  of 
the  stomach — an  excellent  procedure.  Billroth's  second  method — the 
method  employed  by  Mayo — consists  in  performing  gastrojejunostomy. 
With  a  little  practice,  and  in  case  the  stomach  is  freely  movable, 
one  may  perform  the  whole  operation  of  gastrectomy  rapidly,  and  the 
shock  is  less  than  one  might  expect.  In  fairly  vigorous  patients  re- 
action from  the  operation  is  rapid.     After  three  days  of  rectal  feeding 


CAXCKll 


151 


careful  li(iui(l  nourishment  may  be  given  by  mouth,  and  by  the  end  of 
two  weeks  a  fairly  full  diet  with  caution  may  be  prescribed.  These 
patients  should  Ix;  instructed,  however,  that  they  must  never  indulge 
fully  their  vigorous  appetites,  and  should  always  follow  a  careful 
dietar}'. 

Kemoval  of  the  whole  stomach,  with  a  mortality  of  about  39  per 
cent.,  has  been  performed  some  50  times.  So  far  as  the  latest  statistics 
go,  it  appears  that  about  15  per  cent,  of  the  cases  have  been  cured 
permanently.  The  patients,  if  they  survive  the  operation,  show  a 
surprising  increase  in  weight  and  strength,  and  get  along  in  a  fairly 
satisfactorv  manner  so  far  as  their  digestions  are  concerned. 


Fig.  77. — Showing  completed  operation  (after  W.  J.  Mayo,  Ann.  Surg.). 


There  are  two  commonl}'  recognized  palliative  operations  for  cancer 
of  the  stomach — gastro-enterostomy  and  gastrostomy.  The  mortality 
from  gastro-enterostomy  for  malignant  disease  is  higher  than  the  mor- 
tality from  gastrectomy  even — not  that  gastrectomy  is  a  less  severe 
operation,  but  because  gastro-enterostomy  is  performed  in  the  more 
grave  and  hopeless  cases,  on  persons  greatly  reduced  and  with  low 
resisting  powers.  Gastro-enterostomy  is  applicable  to  patients  suffer- 
ing from  pyloric  obstruction,  and  to  these  only.  When  the  cancer  is 
in  the  fundus  of  the  stomach  and  the  pylorus  is  not  involved,  gastro- 
enterostomy is  useless.  Gastro-enterostomy  is  a  makeshift  at  the 
best.  Frequently,  after  submitting  to  it,  patients  improve  for  a  time 
and  are  greatly  more  comfortable  than  before.  They  gain  in  strength, 
flesh,  and  vigor,  and  may  get  about  their  work.     The  average  length 


152 


THK    ABDOMEN 


of  life  aftor  gastro-onterostomy  fur  cancer  of  the  stomach  is  fourteen 
months.  In  advanced  cancer  cases,  with  their  extensive  and  cripphng 
adhesions,  posterior  gastro-enterostomy  rarely  is  aj^plicable.  The 
routine  operation  is  anterior  gastro-enterostomy,  performed  by  suture. 
Gastrostomy,  or  sometimes  jejunostomy,  is  used  in  the  case  of  extensive 
cancer  of  the  fundus  of  the  stomach,  or  when  the  cardia  is  obstructed 
by  disease.  The  purpose  of  the  oi)eration  is  palliation  merely,  in  order 
to  ward  off  starvation.     It  has  no  effect  on  pain  or  vomiting  except  in 


Fig.  78. — Gastrostomy — Witzel's  method  (Keen's  Surge rjO- 


so  far  as  it  removes  irritating  food  fi-om  the  immediate  neighborhood 
of  the  growth. 

The  viscus  to  be  opened  is  drawn  up  to  the  surface,  and  a  ru])l:)er  tube 
or  catheter  is  inserted,  after  the  manner  of  Kader  or  Witzel.  The 
viscus  is  then  attached  to  the  abdominal  wall,  and  the  tube  is  left  pro- 
truding. Through  the  tube  food  is  introduced  at  will.  After  two 
weeks  the  tube  may  be  removed  permanently.  A  fistulous  tract  is  left 
through  which  a  tube  may  be  reinserted  and  food  poured  in  at  any 


SARCOMA    OF    THE    STOMACH 


153 


time.  The  nature  of  the  operation,  if  performed  correctly,  is  such  that 
a  valve-like  obstruction  exists  in  the  fistula,  and  the  stomach-contents 
are  retained  by  the  closed  valve  between  feedings.  By  means  of  this 
operation  a  patient's  life  may  be  prolonged  many  months. 

Besides  cancer,  the  stomach  is  occasionally  the  seat  of  other  tumors, 
both  malignant  and  benign.     Benign  tumors  make  little  trouble  unless 


Fig.  79. — Feeding  by  gastrostomy. 

they  obstruct  the  pyloric  outlet,  and  they  need  not  concern  us  further. 
They  are  rare.  Of  the  other  malignant  tumors,  the  only  one  of  im- 
portance is  sarcoma  of  the  stomach. 


SARCOMA  OF  THE   STOMACH 

This  disease  has  all  the  clinical  characteristics  of  cancer  of  the 
stomach,  and  cannot  with  certainty  be  differentiated  from  it.  Ana- 
tomically, it  is  found  at  the  pylorus  less  frequently  than  is  cancer — 
that  is  to  say,  about  one-fourth  of  the  sarcomata  are  pyloric.  Generally, 
sarcoma  involves  the  posterior  wall  and  the  greater  curvature,  arising 
in  the  submucous  coat.  Whereas  cancer  is  more  common  in  men  than 
in  women,  sarcoma  is  equally  common  in  both.  It  grows  to  a  large 
size  often  before  killing  the  patient,  and  the  tumor  may  be  seen  actually 
distending  the  abdominal  wall.     Hemorrhage  is  not  common;    pyloric 


154  Till-:    AUDO.MK.V 

stenosis  is  not  common;   metastases  are  raic  The  disease  is  rai)i(l,  and 
usually  kills  in  iVom  ten  to  eleven  months. 

The  onl}-  treatment  is  by  operation,  as  in  the  case  of  cancer — 
gastrectomy  or  gastro-enterostomy. 

WOUNDS   OF   THE   STOMACH 

Wounds  of  the  stomach  ha\e  been  considered  alreatly  in  part  under 
the  captions  Wounds  of  the  Intestines  and  Foreign  Bodies  in  the  Stom- 
ach. The  history  of  the  injury  often  gives  little  indication  of  the  extent 
of  the  visceral  lesion.  Damage  is  inflicted  by  blows,  crushes,  and 
})enetrating  missiles  or  stab-woimds.  The  stomach  is  rarely  ruptured 
by  blows  or  crushes.  The  commonest  injuries  are  bullet-wounds  and 
stab-wounds.  The  stomach  differs  from  the  intestines  in  being  a 
thicker-walled  organ,  with  muscular  layers  so  arranged  that  they  are 
less  liable  to  allow  the  escape  of  gastric  contents  than  is  the  intestinal 
wall  to  allow  the  feces  to  escape. 

The  symptoms  of  wounds  of  the  stomach  are :  acute  localized  pain, 
vomiting. — sometimes  bloody, — and  collapse,  with  rapid  pulse  and  a 
falling,  followed  by  a  rising,  temperature.  Later  the  symptoms  of 
peritonitis  supervene.  The  diagnosis  is  often  difficult,  for  a  penetrating 
wound  of  the  stomach  ma}^  exist  without  obvious  striking  sj'mptoms. 

The  treatment  is  immediate  exploration  and  repair  of  the  damaged 
organ.  In  all  cases  of  doubt  it  is  the  surgeon's  duty  to  explore.  The 
stomach  must  be  sewed  up  with  two  rows  of  Lembert  stitches,  the 
abdomen  thoroughly  flushed  with  warm  salt  solution,  and  drainage 
established  at  the  site  of  injury  and  above  the  pubes.  If  convalescence 
proceeds,  the  patient  should  be  nourished  by  nutrient  encmata  for  five 
days  at  least. 

In  addition  to  the  diseases  and  lesions  of  the  stomach  already  dis- 
cussed, there  are  numerous  rare  conditions  and  borderland  diseases 
with  which  the  surgeon  may  occasionall}'  have  to  deal.  Such  are  sundr}- 
forms  of  inflammation,  curious  tumors,  tuberculosis,  and  syphilis. 
The  writers  on  internal  medicine  deal  with  these  matters.  I  refer  the 
reader  to  such  treatises  as  those  of  Xothnagel,  Osier,  Wood,  Fitz,  and 
the  larger  systems  of  surgery. 


CHAPTER  V 

THE  LIVER  AND  BILE-PASSAGES 

The  Liver 

In  general  terms  it  is  convenient  for  the  surgeon  to  regard  the  Uver 
as  an  accessory  digestive  organ — accessory  to  the  stomach  and  in- 
testines, ^loreover,  it  is  interesting  to  reflect  that  by  far  the  most 
important  portion,  surgically,  of  the  liver  apparatus  is  the  system  of 
ducts  connecting  the  Hver  with  the  bowel.  Not  that  the  liver  in  itself 
is  devoid  of  surgical  mterest,  but  such  interest  is  infrequent  compared 
with  interest  in  the  bile-passages.  Though  diseases  of  the  liver  are 
common  in  the  experience  of  the  internist,  it  is  an  unfortunate  fact 


Fig.  SO.— Relations  of  liver. 

that,  as  yet,  surgical  therapeutics  has  found  small  place  in  the  great 
field  of  the  liver  proper. 

There  are  certain  liver  lesions  which  have  always  belonged  to  the 
surgeon,  and  lately  two  or  three  other  diseases  of  that  organ  have  been 
added  to  this  list.  Abscesses,  traumatic  injuries,  cysts,  and  tumors 
are  the  most  important  of  the  lesions  of  the  Hver.  long  recognized  as 
surgical.     Lately,  the  surgeon  has  treated  cirrhosis  and  ptosis. 

Remember  how  the  right  lobe  makes  up  the  bulk  of  the  liver;  how 
the  left  lobe  stretches  out  to  the  left  across  the  epigastrium;  how  the 
broad  suspensory  ligament,  with  its  round  ligament  coming  up  from 

155 


156 


THK    ABDOMEN 


the  navel,  lies  between  the  lobes;  how  the  lower  jiosterior  j)oiiion  of 
the  right  lobe  is  uncovered  of  i)eritoueuni;  how  the  small  (jvia(h-ate 
lobe  appears  in  the  midst  on  the  untler  surface,  with  the  gall-bhitlder 
lying  between  it  and  the  right  lobe,  while  at  its  base  lie  the  ducts,  the 
portal  vein,  and  the  hepatic  artery.  Xormally,  the  liver  is  quite 
movable.  It  may  be  tipped  up  with  the  costal  cartilages.  Xick  the 
suspensory  ligament  with  the  round  ligament,  antl  you  may  pull  the 
liver  down. 

ABSCESS   OF   THE   LIVER 

Abscess  of  the  liver  has  gained  interest  for  American  surgeons 
within  the  past  twelve  j^ears,  because  such  abscesses  are  common  among 
white  men  in  the  tropics.  Our  military  surgeons  are  treating  tropical 
abscess  in  the  Islands,  and  frequent  cases  find  their  way  to  the  States. 
These  tropical  abscesses  are  usually  single.  They  vary  in  size,  but  may 
involve  a  whole  lobe.  Organisms  from  the  intestines  enter  the  ])ortal 
circulation,  and  dysentery  is  the  primary  disease.  Many  observers 
have  found  the  ameba  of  dysentery  in  the  pus  of  these  liver  abscesses. 
Hepatic  abscess  sometimes  follows  malaria,  influenza,  yellow  fever,  and 
tj'phoid.  Henrj'  Jackson,  in  a  resume  of  17  cases  at  the  Boston  City 
Hospital,  found  that  10  of  his  list  were  due  directly  to  a  concurrent  ajjpen- 
dicitis — an  important  observation  of  many  other  writers  also.  There- 
fore, staphylococci  and  streptococci  are  found  in  the  pus,  while,  among 
other  agents,  are  coccidia,  the  ray-fungi  of  actinomycosis,  and  rarely 
tubercle  bacilli.  A  syphilitic  gumma  may  suppurate,  and  s(H'on(lary 
abscesses  due  to  echinococcus  and  cholangitis  occasionally  are  found. 
Moreover,  these  abscesses  may  be  metastatic  and  occur  in  the  course  of 
a  pyemia. 

The  course  of  hepatic  abscess  varies  with  the  nature  of  the  infection. 
Tropical  abscess  grows  slowly;  infections  from  the  appendix  progress 
rapidly.  In  general,  the  pyogenic  organisms  produce  much  more 
acute  inflammations  than  do  the  other  and  more  uncommon  forms. 

The  symptoms  of  liver  abscess  vary  also  with  the  nature  of  the 
infection.  The  tlisease  may  run  its  course  without  symjitoms.  Charac- 
teristic fever,  pain,  tumor,  and  enlarged  liver  rareh'  are  present.  The 
patient  becomes  sallow  and  emaciated,  and  lies  in  a  doubled-up  position. 
There  is  seldom  any  jaundice  of  moment.  If  the  abscess  is  near  the 
liver  surface,  it  may  cause  protrusion  of  the  skin.  If  it  is  in  the  center 
of  the  liver,  it  remains  inconspicuous.  Of  course,  rupture  into  the 
peritoneal  cavity  or  into  adjoining  organs  will  set  up  additional  symp- 
toms of  greater  or  less  gravity,  depending  on  the  locality  thus  invaded. 
None  of  the  classic  signs  of  abscess  are  to  be  looked  for  or  relied  upon. 
Fever  and  a  high-tension,  rapid  pulse  may  or  may  not  be  present.  I 
have  found  the  leukocytosis  varying  from  7000  to  40,000.  Tenderness 
is  generally  absent. 

The  diagnosis  is,  therefore,  extremel}^  difficult  often.  The  condi- 
tion may  simulate  manifold  disorders,  such  as  pleurisy,  subphrenic 
abscess,  disease  of  the  bile-passages,  gastric  ulcer,  pyonephrosis,  pan- 


CYSTS    OF   THE    LIVER  157 

crcatitis,  or  any  other  of  the  comi)lex  conditions  seen  in  the  associated 
neighboring  organs.  Aspiration  may  fail  to  detect  pus  which  is  present, 
but  do  not  aspirate  for  diagnosis.  It  is  a  risky  and  inconclusive  maneu- 
ver. As  with  cancer  of  the  stomach,  an  exploratory  incision  is  justifia- 
ble and  generally  advisable  in  these  obscure  cases  of  suspected  h(!patic 
abscess.  Operate  to  make  the  diagnosis,  and  complete  the  operation 
to  establish  proper  treatment. 

Accordingly,  the  treatment  of  abscess  of  the  liver  is  operative 
except  in  the  early  stages  of  a  suppurative  hepatitis.  Two  methods 
of  operation  have  been  recommended:  complete  operation  at  one 
sitting  and  operation  in  two  stages — I  prefer  the  former.  Open  down 
upon  the  suspected  region,  wall  off  the  Hver  with  gauze,  open,  wash 
out,  and  drain  the  abscess.  If  the  Hver  has  become  adherent  to  the 
abdominal  wall,  the  operation  is  by  so  much  the  easier.  Operation 
in  two  stages  consists,  first,  in  exposing  the  suspected  area  and  stitching 
the  parietal  peritoneum  to  the  hver  about  the  lesion.  Then,  after  ten 
days,  adhesions  will  have  formed,  when  the  abscess  may  be  opened. 
Under  the  conditions  of  modern  technic  this  cumbersome  procedure  is 
seldom  necessary. 

In  the  case  of  actinomycosis,  as  with  actinomycosis  elsewhere,  fol- 
low the  operation  with  medication  by  copper  sulphate  or  potassium 
iodid. 

CYSTS  OF  THE   LIVER 

Cysts  of  the  Hver  are  variously  described  by  writers,  but  you  will 
find  in  practice  that  the  echinococcus  cyst  alone  is  important.  It  is  due 
to  the  Tsenia  echinococcus,  a  tape-worm  of  4  joints,  measuring  about 
0.2  inch.     This  parasite  is  found  in  the  duodenum  of  dogs  and  a  few 


Fig.  81. — Diagram  of  cyst  of  liver. 

other  domestic  animals.  The  embryo  finds  its  way  into  the  human 
Hver  and  develops  slowly.  It  is  found  surrounded  by  a  capsule  of 
connective  tissue,  within  which  is  the  cuticle  of  the  cyst,  lined  with 
parenchyma,  from  the  ceUs  of  which  develop  the  scolices  or  heads  of  the 
tape-worms.  These  scoHces  have  suckers  surrounded  by  booklets. 
The  fully  developed  scolices  are  detached  from  the  membrane  and  float 
free  in  the  cavity  of  the  cyst,  which  contains  a  clear  fluid,  nearly  color- 
less.    These  cysts  may  exist  undiscovered  for  years.     They  grow  slowly, 


158  THF,    AUDO.MEM 

and  may  never  cause  sym])t()nis.  unless,  from  their  size,  they  distend 
the  liver,  press  upon  neighhorinji;  ()r<ians,  and  I'upture  or  become  in- 
fected. 

So  the  symptoms  vary  as  nnich  as  do  the  symptoms  of  liver  ab- 
scess. When  the  tumor  is  small  and  deep,  it  is  unnK-ognized.  When  it 
is  recognized,  it  appears  connected  with  the  liver,  rounded,  smooth,  and 
elastic.  Sometimes  it  causes  pain;  it  moves  with  respiration.  If  it 
suppurate,  it  will  have  the  characteristics,  or  lack  of  characteristics, 
of  hepatic  abscess.  On  such  indefinite  evidence  the  diagnosis  must  be 
made. 

The  treatment  is  like  that  for  abscess,  and  exploratory  operation 
often  is  needed  both  to  confirm  the  diagnosis  and  to  relieve  the  condi- 
tion. The  conservative  method  is  to  evacuate  the  fluid  and  other 
contents,  to  break  up  supplementary  or  "daughter  cysts,"  which  are 
frequently  found,  and  to  pack  the  wound,  leaving  it  to  heal  by  granula- 
tion— a  slow  process,  requiring  weeks  or  months.  A  more  radical, 
bloody,  and  somewhat  dangerous  method  is  to  enucleate  the  cyst  with 
curet  or  cautery.  If  successful,  this  method  is  followed  by  healing 
in  three  or  four  weeks.  One  might  discuss  at  length  methods  of  open- 
ing down  upon  these  liver  cysts.  Generally,  they  may  be  approached 
through  an  abdominal  incision.  Sometimes  one  must  remove  the  lower 
costal  cartilages  and  ribs,  pack  off  the  pleural  cavity,  and  enter  through 
the  diaphragm. 

In  all  cases  the  after-treatment  must  be  pursued  energetically  with 
local  irrigations  and  packing  and  by  general  sustaining  treatment. 

INJURIES  TO   THE   LIVER 

Injuries  to  the  liver  are  common  in  military  and  railway  surgery. 
Ruptures  and  penetrating  wounds  frequently  are  seen.  The  right 
lobe  most  often  is  ruptured,  and  the  tear  may  be  slight  or  extensive. 
Lacerations  of  this  gland  are  often  wide,  because  it  is  inelastic.  These 
cases  are  dangerous,  and  the  mortality  is  nearly  50  per  cent,  under 
the  most  favoring  circumstances.  Most  of  the  patients  who  die  perish 
within  twenty-four  hours  from  hemorrhage.  Among  those  who  live 
longer,  peritonitis  and  ptomain  poisoning  may  supervene. 

The  symptoms  are  the  symptoms  of  acute  intra-abdominal  hemor- 
rhage, plus  pain,  while  the  shock  is  often  out  of  proportion  to  the  bleed- 
ing. Severe  and  continuous  ])ain  in  the  abdomen — jxiin  both  local  and 
general — persists.  It  does  not  intermit.  It  may  radiate  toward  the 
navel  and  the  right  shoulder.  Sometimes  there  is  late  jaundice.  Bile 
may  appear  in  the  urine. 

The  treatment  must  be  heroic;  rarely  is  delay  permissible.  With 
evidence  before  him  of  severe  injury,  pain,  abdominal  hemon-hage,  and 
profound  shock,  the  surgeon  must  open  the  abdomen  at  once  through 
a  long  incision  in  the  right  semilunar  line,  or  through  a  sweeping  in- 
cision parallel  to  the  margin  of  the  ribs.  Thus  he  will  discover  blood 
and  clots.     If  one  fails  to  find  at  once  the  rent  in  the  liver,  or  if  it  is 


TUMORS    OF    THE    LIVER 


159 


evident  that  the  organ  is  wounded  on  the  convexity  of  the  right  lobe, 
up  under  the  diaphragm,  one  may  employ  Lannelongue's  plan  to 
reach  the  seat  of  injury — that  is.  through  a  curved  incision  two  inches 
above  and  {parallel  to  the  border  of  the  ribs;  and  by  resecting  the  eighth, 
ninth,  tenth,  and  eleventh  costal  cartilages.  When  the  rent  in  the 
liver  is  found,  it  must  be  treated  with  deep  sutures,  threaded  on  a 
blunt  needle,  by  the  cautery,  or  by  tampon.  I  prefer  to  use  heavy, 
buried  catgut  stitches,  carefullj^  opposing  the  torn  capsule.  The  abdom- 
inal cavity  must  be  mopped  out,  and  the  external  wound  must  be 
closed  with  drainage.     Liun-shot  and  stab-wounds  must  be  treated  in 


Fig.  S2. — Transthoracic  approach  to  the  liver. 

much  the  same  fashion,  except  that  in  such  cases  the  cautery  and 
tampon  are  often  better  than  stitches.  If  ribs  or  cartilages  have  been 
resected,  the  surgeon,  in  closing  the  wound,  must  see  to  it  that  sharp, 
bony  edges  do  not  lacerate  the  exposed  liver.  Convalescence  from 
these  injuries  is  surprisingly  rapid  often. 


TUMORS   OF   THE   LIVER 

SoHd  tumors  of  the  liver  focus  the  subject  of  hepatic  surgery,  a 
subject  of  growing  interest.  We  have  seen  how  wounds  of  the  liver 
were  regarded  for  long  as  extremelv  fatal,  because  it  is  hard  to  control 


160 


THE    ABDOMEN 


hepatic  hcniorrluiiro.  On  account  of  hcniorrhajic  it  has  been  thoufiht 
difficuh  or  ini]jossil)k'  also  to  cut  clown  into  the  hvcr  safely  in  order  to 
remove  a  tumor.  Thanks  to  the  endeavors  of  recent  experimenters, 
we  are  now  coming  to  feel  that  we  can  cut  into  the  liver  with  reasonable 
confidence.  But  we  do  not  yet  attempt  extensive  explorations  of  that 
organ,   nor  try   to  remove  its  multiple  tumors — and,   unfortunately, 


Fig.  83. 


-Knott's  method  of  suturincr  tlie  liver.     The  sunken  catgut  stramls  in  the 
tissue  parallel  to  the  wound  to  be  sutured. 


multiple  tumors  of  the  liycv  are  more  frequent  than  are  solitary  tumors. 
Of  the  hver  tumors,  syphilomata  are  common.  They  occur  in  two 
forms:  as  circumscribed  gummata  and  as  syphilitic  lobulation.  A 
gumma  is  usuall}-  single,  and  may  grow  to  the  size  of  a  hen's  egg,  being 
situated  near  the  suspensory  ligament  usually  or  near  the  entrance 
of  the  portal  vein.  Lobulation  results  from  cicatricial  contraction  fol- 
lowing the  absorption  of  syphilitic  nodules. 


Fig.  84. — Knott's  method  of  suturing  the  liver.     Tlie  transverse  interrupted  sutures 

introduced. 

The  symptoms  of  syphilitic  liver  are  indefinite  and  somewhat  various. 
The  first  evidence  is  often  a  movable  lobe  suggesting  floating  kidney, 
or  there  may  be  ascites,  due  to  pressure  on  the  portal  vein;  jaundice 
is  .rare.  These  tumors  cannot  always  with  certainty  be  differentiated 
from  cancer,  even  when  the  abdomen  is  opened.  It  is  seldom  wise  to 
attempt  a  removal  of  a  syphilitic  nodule,  because  specific  treatment 
will  frequently  suffice  to  subckie  the  symptoms.     If  a  partiall}'  detached 


TUMORS   OF   THE    LIVER 


IGl 


lobe  protrudes,,  however,  and  makes  trouble,  it  mav  be  removed  with 
the  cautery,  and  the  hemorrhage  may  be  controlled  by  such  deep 
stitchmg  as  I  shall  describe  presently.  Some  six  years  ago  I  removed 
such  a  lobe  from  the  liver  of  a  woman  who  had  complained  for  several 
years  of  constant  abdominal  pain.  The  result  was  entirelv  satisfactory 
In  her  case,  before  operation,,  the  tumor  was  supposed  to  be  a  floatincr 
kidne}'.  '^ 

There  are  sundry  benign  tumors  of  the  liver— fibromata,  fibro- 
myomata,  angiomata,  and  adenomata.  These  are  important  when  they 
obstruct  the  circulation  or  press  upon  neighboring  organs.  Thev  may 
be  removed  with  the  knife  or  cauterv.  "      "  •'J 

Cancer  of  the  liver  is  common,  and  is  generaUv  secondarv  to  cancer 
elsewhere— m  the  stomach,  the  bile-passages,  or  some  portion  of  the 
mtestmal  canal.  Secondary  cancer  of  the  Uver  develops  about  many 
foci,  or  IS  multiple,  as  we  say.  One  should  never  attempt  its  removal 
Primaiy  cancer  of  the  Hver  rarely  may  be  multiple  or  infiltrating.  In 
the  case  of  sohtary  primary  cancer,  excision  sometimes  conceivably 
is  permissible.  Unfortunately,  primar^^  cancer  of  the  Hver  rarelv  is 
detected  until  it  is  too  large  for  removal. 


Fig.  85.— Knott's  method  of  suturing  the  liver.     The  transverse  sutures  tied. 

The  sij)nptoms  of  primary  hepatic  cancer  are  the  general  symptoms 
of  cancer  with  certain  special  late  manifestations.  The  patient  be- 
comes cachectic  and  loses  his  appetite,  especially  for  fattv  foods  and 
meat;  and  there  may  be  vomiting  of  blood,  due' to  passive  congestion 
of  the  gastric  mucosa.  The  Hver  becomes  sHghtly  enlarged;  rarely,  a 
tumor  may  be  felt ;  there  may  be  ascites,  and  there  'may  belate  jaundice, 
but  if  ascites  and  jaundice  are  present,  the  disease  is' too  far  advanced 
for  radical  treatment. 

Primary  sarcoma  of  the  liver  is  stiH  rarer  than  carcinoma,  and  the 
S}-mptoms  of  the  two  cannot  be  distinguished  from  each  other. 

Treatment  of  Liver  Ttmiors.— Excision  of  Hver  tumors  is  the  only 
radical  treatment  possible,  and  of  late  such  operations  have  multipHed. 
They  aU  depend  upon  hemostasis  for  their  success.  The  mere  cutting 
out  of  a  tumor  of  this  organ  is  as  easy  as  cutting  cheese,  but  the  control 
of  hemorrhage  is  the  problem.  Tumors  of  the  left  lobe  are  the  most 
easy  to  remove,  because  the  left  lobe  itself  can  be  amputated.  Indeed, 
it  was  long  ago  proved  by  numerous  experimenters  that  large  portions 
11 


162  THE    AHDOMICM 

of  the  livtM-  may  be  removed  without  danger  to  life,  riifortuiiatcly, 
primary  cancer  usually  is  found  in  the  ri(/lit  lobe.  The  literature  of 
operations  on  the  liver  is  now  considerable,  and  advertises  the  names  of 


Fig.  86. — Excision  of  section  of  liver.  Method  of  checking  hemorrhage  by  com- 
bined catgut  suturing  and  gauze.  Compression  seen  from  above  (Mayo,  in  Keen's 
Surgery). 

Holm  (1867),  Tillmanns  (1879),  Escher  (1886),  Burkhardt  (1887)— the 
first  to  insist  upon  abdominal  section  to  control  hepatic  hemorrhage; 
Gliick  (1890),  who  demonstrated  that  one-third  of  the  liver  may  be 


Fig.  87  — Same  as  Fig.  86,  seen  from  beneath  (Mayo,  in  Keen's  Surgerj-)- 

removed  safely;  and  Ponfick  (1895).  The  experiments  of  these  in- 
vestigators encouraged  many  surgeons  to  operate  upon  and  report 
cases  of  liver  tumor,  all  their  work  being  directed  toward  improving 


CIKRHOSIS   OF   THE    LIVER  163 

tho  methods  of  controlling  hemorrhage.     Kousnetzoff  and  Penski,  in 
1S94,  devised  an  ingenious  method  of  constricting  with  mattress  sutures 
the  operation  field  in  the  hver,  and  their  method  or  its  modifications 
still  maintain.     A  more  important  detail  of   their  plan  is  the  use  of 
blunt  needles,  which  may  be  carried  readily  through  liver  tissue  without 
wounding  vessels.     A  series  of  these  sutures  is  passed  as  illustrated 
in  the  cuts;   the  liver  tissue  is  thus  constricted,  and  the  tumor  with  a 
V-shaped  section  of  the  organ   itself  is  removed.     The  wide  wound  is 
then  sewed  up  tight,  the  Hver  capsule  repaired,  and  the  abdominal 
wound  closed  without  drainage.     Jacob  Frank,  in  1905,  developed  a 
method  of  suturing  the  liver  which  is  described  briefly  as  follows: 
After  excising  a  wedge-shaped  portion  of  the  liver,  '^the  two  broad 
raw  surfaces  left  by  the  removal  of  the  wedge-shaped  piece  are  now 
converted  into  troughs.     This  is  accomplished  by  the  excision  of  wedge- 
shaped  pieces,  the  troughs  thus  formed  each  having  two  flaps.     When 
the  operation  is  completed,  the  raw  surfaces  of  the  original  V  left  are 
transformed  into  smooth,  continuous  liver  tissue,  assuming  the  form 
of  liver  borders,  and  the  V  space  left  persisting  as  a  notch.     This  method 
of  incising  the  Hver  facilitates  easy  suturing."     Keen,  in  1899,  reported 
an  interesting  case  of  removal  of  the  left  lobe  with  the  cautery;  while 
Kocher  has  advocated  the  use  of  heavy  compression  forceps  to  seize 
and  crush  the  bleeding  points.     He  leaves  the  forceps  in  place  for 
twenty-four  hours,   a  disadvantage  necessitating  their  removal  later 
through  an  open  abdominal  wound. 

Such  is  the  status  of  the  excision  of  Hver  tumors.  In  spite  of  the 
enthusiasm  of  surgeons  and  the  promise  of  widening  the  field  for  such 
work,  the  unfortunate  fact  remains  that  few  of  these  tumors  are  single 
and  susceptible  of  removal. 

Within  recent  years  more  or  less  successful  attempts  have  been  made 
to  operate  upon  two  other  forms  of  liver  disease — cirrhosis  and  ptosis; 
but,  unfortunately,  the  results  of  these  operations  are  proving  less 
promising  than  at  first  was  hoped. 

CIRRHOSIS  OF  THE   LIVER 

Cirrhosis  of  the  Hver  in  all  its  manifestations  is  not  susceptible  of 
operative  treatment.  R.  B.  Greenough  ^  summed  up  the  facts  in 
1902,^  and  Httle  of  value  has  been  added  to  what  he  then  wrote.  The 
famiHar  operation  for  cirrhosis  is  credited  to  Talma,  of  Utrecht,  though 
Greenough  points  out  that  Morrison  and  Drummond,  of  Newcastle, 
were  the  first  to  make  it  practicable.  Talma's  theory  of  the  operation 
was  based  upon  his  observations  at  autopsy  that  cases  of  Hver  cirrhosis 
which  showed  the  least  ascites  were  those  in  which  abundant  anas- 
tomoses existed,  through  the  preexisting  channels,  and  through  ac- 
cidental adhesions  between  the  vessels  of  the  portal  system  and  those 
of  the  systemic  circulation.  By  multiplying  the  adhesions  he  hoped 
to  multiply  the  anastomoses,  and  thus  diminish  the  portal  congestion. 

-  R.  B.  Greenough,  Amer.  Jour.  Med.  Sci.,  December,  1902. 


164 


THE    AHDO.MKN 


It  is  obvious  that  even  if  ahuiuhint  collateral  anastomoses  arc  thus 
established,  so  that  the  liver  circulation  is  relieved,  still  little  improve- 
ment in  the  disease  process  within  the  Hver  can  be  anticipated.  More- 
over, considerable  experience  has  now  shown  that  Talma's  operation 
is  api)licable  in  cases  of  hypertrophic  cirrhosis  only,  and  not  to  cases 
of  atrophic  cirrhosis — certainly  not  to  cases  of  acute  yellow  atrophy.' 
Quite  another  operation,  devised  by  Terrier,  of  Paris,  is  performed  for 
that  condition  known  as  biliary  ciri'hosis — the  "  Hanot's  cirrhosis"  of 
the  French.  The  presumption  is  that  bihary  ciri'hosis  is  due  to  an 
infection  of  the  liver  through  the  bile-passages.     Tenier,  and  later  Dela- 


Fig.  88. — Schiassi's  modification  of  Talma's  operation. 


geniere,  undertook  to  side-track  the  infecting  bile,  and  so  to  relieve 
the  hver,  by  draining  the  gall-ducts  through  the  gall-bladder — chole- 
cystostomy.  In  certain  cases  this  operation  has  been  beneficial.  M, 
L.  Harris,  in  an  admirable  essay  in  1903,  pointed  out  that  the  two 
forms  of  cirrhosis  susceptible  of  surgical  treatment  sometimes  may  co- 
exist, and  he  advocated  a  combination  of  Talma's  ojjeration  with  gall- 
bladder drainage  in  suitable  cases.  Gall-bladder  drainage  is  indicated 
when  there  is  evidence  of  hepatic  infection — localized  pain  over  the 

1  See  account  of  case  reported  by  Wilder  Tileston,  in  Boston  Med.  and  Surg. 
Jour.,  1908,  vol.  clviii,  p.  609. 


HEPATOPTOSIS 


165 


bile-ducts,  tenderness,  fever,  chills,  enlarged  liver,  occasional  jaundice, 
but  no  ascites. 

Talma's  method  of  establishing  a  collateral  anastomosis  around 
the  liver  is  known  as  omentopexi/ — fastening  the  omentum  to  the 
parietal  peritoneum.  The  omentum  carries  veins  to  the  portal  system, 
and  these  veins,  through  omental  adhesions  to  the  abdominal  wall,  may- 
be made  to  connect  with  radicles  of  the  parietal  veins.  Sundry  modi- 
fications of  Talma's  method  have  been  advocated,  such  as  laying  the 
omentum  between  the  abdominal  muscles,  or  the  more  radical  pro- 
cedure of  Schiassi  ^ — omentopexy  plus  splenopexy.     Abdominal  drain- 


^S"-''i-h. 


Fig.  89. — Schiassi's  operation. 


Fig.  90. — Schiassi's  operation. 


age  should  not  be  used  after  these  operations,  but  occasional  tappings 
may  be  employed  until  the  sought-for  collateral  anastomosis  is  estab- 
hshed.  These  operations  are  not  to  be  used  in  cases  of  ascites  due  to 
causes  other  than  cirrhosis  of  the  liver;  and  the  selection  of  cases 
suitable  for  operation  demands  careful  judgment. 


HEPATOPTOSIS 

Hepatoptosis,  or  dislocation  of  the  liver,  is  another  subject  which 
has  exercised  surgeons  of  late.  It  is  important  not  alone  for  the  im- 
mediate symptoms  it  causes,  but  because  usually  it  is  associated  with 
derangements  of  other  organs.  It  is  associated  with  other  ptoses. 
Moreover,  it  may  give  rise  directly  to  disease  of  the  bile-ducts,  stomach, 
pancreas,  duodenum,  kidney,  and  appendix. 

Writers  talk  about  partial  and  complete  hepatoptosis.  There  is  no 
such  thing  as  partial  hepatoptosis.  They  mean  by  the  term  a  partial 
cutting  off  and  dropping  of  a  piece  of  the  right  lobe.  Tight  lacing  is 
the  common  cause.  The  deformity  is  found  among  women,  mostly. 
As  a  result  of  this  partial  cutting  off  of  the  right  lobe  there  are  symptoms 
1  Semaine  Med.,  May  27,  1903. 


166 


TIIH    AKDOMKN 


of  pain  and  (Irajrginfi.  Tlu^  blood-suj^ply  to  the  constricted  part  may 
become  ohstnictcd,  with  stran^uhition  and  j)eritoneal  involv(!ment. 
In  mild  cases  there  are  commonly  associated  nervous  phenomena  and 
digestive  disturbances — anorexia,  flatulence,  constipation,  ])ain,  nausea, 
and  vomiting. 

The  diagnosis  of  this  lesion  of  the  right  lobe  is  always  obscun;,  for 
the  separated  portion  nuist  be  felt  to  be  identified,  and  even  when  felt, 
it  simulates  a  movable  kidney,  a  liver  tumoi',  or  a  distended  gall-bladder. 
It  stretches  down  into  the  right  inguinal  region  or  the  right  loin,  and, 
rarely,  may  reach  the  ])ubes. 

The  treatment  is  palliative  and  radical.  You  may  support  the 
hanging  mass  and  relieve  symptoms  by  bandaging  (see  Chapter  IX),  or 
you  may  amputate  the  offending  portion,  using  the  cautery  and  through- 
and-through  mattress  stitches  to  control  hemorrhage.  Sometimes  the 
isthmus  consists  of  little  more  than  fibrous  tissue,  with  a  small  amount 


Fig.  91. — Application  of  bandage  for  alidominal  ptosis. 

of  liver  substance.     As  a  rule,  the  operation  is  not  dangerous  in  skilled 
hands,  and  the  relief  to  the  patient  is  often  remarkable. 

Total  hepatoptosis  is  becoming  recognized  as  a  somewhat  frecjuent 
condition,  and  sundry  surgeons,  notably  Ellsworth  Eliot,  Jr.,  have 
devised  operations  for  its  relief.  The  liver  descends  en  masse,  and 
partially  rotates  on  itself.  Generally  its  displacement  is  but  slight; 
rarely  it  sinks  deep  in  the  abdomen.  As  with  "partial"  hepatoptosis, 
the  symptoms  are  due  mostly  to  pressure  on  other  organs.  There  is 
pain,  which  may  become  agonizing  and  come  on  in  ciises.  Often  the 
pylorus  is  dragged  upon,  so  that  it  becomes  kinked,  with  a  resulting 
gastrectasis.  There  is  frequently  an  associated  bile-duct  disease 
with  jaundice;  sometimes  portal  obstruction  with  ascites.  Indeed, 
there  are  manifold  and  puzzling  symptoms  of  recurring  or  persistent 
severe  digestive  disorders.  The  diagnosis  is  made  by  finding  a  great 
solid,  movable  abdominal  tumor  and  noting  the  absence  of  the  liver 
from  its  proper  site. 


THK    HILK-I'ASSAGES  107 

The  treatment  of  liver  ptosis  is  one  of  the  most  difficult  of  surgical 
problems.  Floating  liver  is  so  commonly  associated  with  other  floating 
organs  that  one  may  be  at  a  loss  where  to  begin  treatment  and  what 
organ  to  attack.  For  this  reason  it  is  well,  primarily,  to  undertake 
g(Mieral  measures  applied  to  all  the  abdominal  organs :  tonics,  laxatives 
(nux  vomica,  iron,  Carlsbad  salts),  massage,  exercises  designed  to 
strengthen  the  abdominal  muscles,  cold  baths,  open-air  life,  and,  most 
important  of  all,  the  wearing  of  a  carefully  applied  bandage  or  binder. 
Then  there  are  various  operations,  all  of  which  are  still  on  trial.  The 
liver  may  be  pushed  up  into  place  and  held  there  by  stitching  the  round 
ligament  and  the  spread-out  falciform  hgament  high  on  the  abdominal 
wall  (Eliot).  Surgeons  have  fastened  the  liver  to  the  costal  cartilages. 
The  lower  edge  of  the  liver  may  be  pocketed  high  behind  the  parietal 
peritoneum  (after  Rydygier's  splenopexy),  and  the  distressing  ascites 
may  be  treated  by  Talma's  operation. 

Notable  benefit  has  resulted  from  some  of  these  operations,  and  we 
are  encouraged  to  persevere  on  such  lines  for  the  solution  of  the  problem.^ 

"Riedel's  lobe''  is  a  downward  projection  from  the  right  lobe  of 
the  liver,  immediately  to  the  right  of  the  gall-bladder.  Riedel's  lobe 
is  usually  associated  with  gall-stone  disease.  Cholecystostomy  will 
bring  often  a  disappearance  of  this  abnormal  projection,  though  its 
amputation  may  be  necessaiy  at  times. 

Aneurysm  of  the  hepatic  artery,  a  very  rare  disease,  has  never 
been  operated  upon.  The  symptoms  resemble  those  of  bile-passage 
disease.  If  the  true  condition  be  ascertained,  it  is  proper  to  tie  or 
excise  the  vessel. 

The  Bile-passages 

The  passages  which  drain  bile  from  the  liver  into  the  intestines  are 
of  more  surgical  interest  than  is  the  liver  itself,  and  the  problems  of  bile- 
passage  disease  are  intricate  and  puzzling.  Yet  these  problems  are  made 
needlessly  obscure  often  by  the  use  of  a  multiplication  of  names  and 
terms,  and  the  confounding  of  cause  with  effect.  Students  hear  of 
gall-stone  disease,  cholangitis,  and  cholecystitis,  and  are  wont  to  conclude 
that  these  are  definite  entities,  to  be  studied  separately.  Then,  at 
autopsy  or  operation,  they  see  two  or  more  of  these  entities  present  at 
once,  and  so  their  puzzlement  grows. 

We  had  best  discard  terms,  or  use  them  with  their  relative  signifi- 
cance. We  are  discussing  disease  of  the  bile-passages — of  a  S3'stem  of 
passages.  The  gall-bladder  is  but  a  part,  of  the  system;  cholangitis 
and  cholecystitis  are  but  special  manifestations  of  a  progressive  bile- 
passage  disease.  We  have  to  deal  with  infection,  inflammation,  stone- 
formation,  suppuration,  ulceration,  cicatrization,  stenosis,  perforation, 
fistula  formation,  adhesions,  peritonitis,  local  or  general,  mahg-nant 
changes,  and  the  involvement  of  other  organs. 

The  underlying  cause  of  all  this  is  an  infection,  conveyed  upward 

1  B.  G.  A.  Moynihan  (Abdominal  Operations,  1905,  p.  108)  makes  some  interest- 
ing suggestions. 


1G8  THK    AUDOMKX 

along  the  coinmon  duct  generally,  to  the  ey^stie  duct,  the  gall-bludder, 
and  the  hepatic  duct.  Perhaps  the  infection  may  come  at  times  through 
the  blood-stream.  At  any  rate,  there  is  an  invasion  of  organisms — 
pyogenic  cocci,  colon  bacilli,  the  Bacillus  tyj^hosus,  the  pneuniococcus. 
Then  there  result  the  same  conditions  as  are  always  found  when 
mucous  membranes  are  attacked  by  such  organisms,  plus  special  con- 
ditions due  to  the  presence  of  bile — swelling  of  the  mucosa  in  the  ducts, 
obstruction  and  stagnation  of  bile,  and  a  precipitation  of  cholesterin 
from  the  irritated  cj)ithelial  cells — stones  are  formed  from  such  a  {jre- 
cipitate.  The  stones  in  their  turn  may  irritate  the  mucosa,  causing 
abrasions  and  ulcerations;  more  organisms  find  lodgment  here,  and 
the  process  may  go  on  developing  indefinitely,  or  the  process  may 
become  quiescent,  sometimes  leaving  stones  harmlessly  lodged  in  the 
gall-bladder  and  passages,  sometimes  with  the  escape  of  stones  and 
the  restoration  of  a  normal  condition.  Or  a  persistent  inflammation 
may  become  established,  leading  to  the  extensive  complications  and 
cripplings  which  I  have  named.  All  these  phenomena  are  part  of  a 
chronic  process. 

There  are  acute  inflammations  also — acute  from  the  outset,  or  im- 
planted upon  the  chronic  process.  Stones  are  a  result  of  chronic  in- 
flammation, not  of  acute  inflammation.  Acute  inflammations  are 
urgently  serious  affairs;  they  go  on  rapidly  to  suppuration,  ulceration, 
and  gangrene  even. 

Chronic  indolent  catarrh  is  the  important  factor  in  the  etiology  of 
calculi.  But  chronic  catarrh  may  exist  for  a  long  time  and  cause 
distressing  symptoms,  without  leading  to  stone  formation.  The  symp- 
toms may  suggest  the  presence  of  stones,  and  operations  to  relieve  the 
symptoms  may  properly  be  done.  Stones  actually  present  are  not  the 
sine  qua  non  of  bile-passage  disease. 

Cholangitis  means  an  inflammation  of  the  passages — such  inflamma- 
tion, acute  or  chronic,  as  I  have  described,  and  the  reader  will  note 
that  a  certain  degree  of  cholangitis  is  a  prerequisite  to  stone-formation. 
Cholangitis  may  subside  and  stones  be  left. 

Cholecystitis  is  merely  a  cholangitis  confined  to  the  gall-bladder, 
and  catarrh  of  the  gall-bladder  is  apt  to  be  a  more  indolent  disease  than 
catarrh  elsewhere  in  the  bile-passages.  So  it  is  in  the  gall-bladder  that 
stones  are  wont  commonly  to  form.  Stones  may  form  in  the  gall- 
bladder and  then  pass  into  the  ducts,  or  they  may  form  primarily  in  any 
part  of  the  bile-passages.  Stones  give  rise  to  a  variety  of  symptoms 
according  to  their  size,  number,  mobility,  and  location. 

The  anatomic  relation  of  the  bile-ducts  to  the  pancreas,  duo- 
denum, and  stomach  is  important.  In  some  90  per  cent,  of  cases  a  small 
section  of  the  common  duct  lies  within  the  substance  of  the  head  of 
the  pancreas,  in  close  relation  with  the  pancreatic  duct  (duct  of  Wir- 
sung).  A  section  of  the  common  duct  lies  also  against  the  posterior  wall 
of  the  duodenum,  while  toward  its  end  the  common  duct  traverses  the 
wall  of  the  duodenum,  ending,  together  with  the  duct  of  AVirsung,  in  the 
ampulla  of  Vater.     The  gall-bladder  also  lies  close  to  the  duodenum. 


THE    BILE-PASSAGES 


169 


to  which  it  may  become  adherent;  and  just  below  the  gall-bladder  runs 
the  transverse  colon.  So  observe  that  numerous  structures — the  gall- 
bladder, the  ducts,  the  head  of  the  pancreas,  the  portal  vein,  the  duo- 
denum, the  transverse  colon,  and  the  right  kidney — all  lie  packed 
together  in  an  area  which  may  be  covered  by  a  child's  palm.  It  is  this 
close  anatomic  arrangement  which  leads  often  to  a  confusion  of  s}'mp- 
toms  and  to  a  confounding  of  disease  of  one  organ  with  disease  of 
another.  It  is  owing  to  this  anatomic  relationship  also  that  diseases 
of  adjacent  organs  frequently  coexist;  gastric  and  duodenal  ulcer  with 
cholangitis,  and  cholangitis  with  pancreatitis.  When  one  takes  this 
broad  general  view  of  so-called  gall-stone  disease,  one  sees  that  the 
symptoms,  the  prognosis,  and  the  treatment  indicated'  must  change 
with  the  progress  of  the  disease.     Therefore,  let  us  take  up  briefly  a  study 


Common  bile  duetT 
<ScintorLnt  dueV. 


Fig.  92. — Relations  of  bile  and  pancreatic  ducts  (schematic). 


of  symptoms  and  the  corresponding  pathologic  changes,  with  the  ap- 
propriate treatment. 

Symptoms. — Writers  assert,  and  3'ou  will  be  told,  that  of  all  persons 
with  gall-stones,  5  per  cent,  only  know"  it  or  are  troubled  by  symptoms. 
This  is  misleading,  and  depends  upon  the  personal  equation  of  patients. 
The  fact  is  that  there  may  be  and  often  is  a  long  train  of  uncomfortable 
sensations  leading  up  to  the  formation  of  actual  gall-stones.  One  must 
be  suspicious  on  hearing  of  such  symptoms  as  discomfort,  "  all-goneness," 
distress,  anorexia,  nausea,  headache,  flatulence,  constipation,  malaise, 
malnutrition,  continuous  or  repeated  and  running  over  an}'  considerable 
period  of  time.  Such  symptoms  may  mean  many  things,  but  often 
the}'  mean  trouble  in  the  bile-passages.  Often  there  is  an  associated 
tenderness  in  the  right  hypochondrium  over  the  ducts,  or  at  "Robson's 


170  THK    A|{I)().MK.\ 

point/'  midway  between  the  right  costal  margin  and  the  navel.  Some- 
times pressure  with  the  finger  at  a  point  one  inch  to  the  right  of  the 
navel  will  elicit  ])ain,  as  pointed  out  by  Robert  Morris. 

All  these  signs  and  symptoms  may  subside  and  recur,  and  may  be 
associated  further  with  distress  after  food,  indefinite  but  sharp  occa- 
sional pains  in  the  upper  part  of  the  abdomen,  a  bad  taste  in  the  mouth, 
furred  tongue,  frequent  headaches,  diminished  diaphoresis,  high- 
colored  urine,  and  frequent  blurring  of  vision.  Such  j^atients  will  tell 
you  that  they  are  "bilious." 

When  you  have  to  deal  Avith  a  "bilious"  patient,  remember  that 
the  true  condition  may  be  one  of  beginning  infection  of  the  bile-passages, 
and  may  be  the  precursor  of  stone-formation,  with  the  classic  pain  and 
icterus.  It  is  impossible  to  say  just  what  is  the  pathologic  condition 
present  in  each  ease.  There  may  be  a  slight  catarrh  only  of  the  pas- 
sages; there  may  be  a  chronic  thickening  of  the  ducts;  there  is  almost 
always  a  diminished  passage  of  bile;  there  may  be  stones  formed 
already  in  the  gall-bladder. 

The  treatment  of  patients  wuth  these  mild  indefinite  symptoms  is 
not  operative,  as  a  rule.  These  are  the  patients  who  are  "cured"  by 
Carlsbad  treatment,  change  of  air  and  scene,  recreation,  a  carefully 
regulated  life,  a  restricted  diet,  exercise,  massage,  proper  bathing, 
and  the  abundant  drinking  of  saline  waters,  the  effect  of  all  of  which 
is  obvious  enough.  The  patient's  general  condition  is  improved,  the 
systemic  circulation  is  stimulated,  and  the  affected  parts  are  flushed. 
Passive  hyperemia  is  diminished,  catarrh  is  relieved,  local  swelling 
subsides,  and  normal  drainage  of  the  ducts  is  rcestablisluxl.  In  a  few 
weeks  the  sufferer  is  well,  and  he  may  continue  well  indefinitely.  Per- 
haps he  had  gall-stones  in  addition  to  the  inflammation,  but  if  so,  the 
stones  were  in  the  gall-bladder,  and  they  are  there  still.  They  are 
not  removed  by  medication.  They  may  or  may  not  cause  subsequent 
trouble.  But  the  patient  is  cured  of  his  symptoms,  and  that  is  what 
he  cares  most  about.  It  is  as  well,  perhaps,  to  leave  without  operation 
these  cases  of  apparent  cure.  They  may  remain  well  for  a  life-time, 
and  if  they  relapse,  then  is  the  time  for  operation.  There  are  cogent 
arguments,  however,  against  this  let-alone  course,  one  argument  being 
that  long-continued  gall-stone  irritation  may  lead  to  malignant  changes 
in  the  tissues  affected.     I  shall  discuss  that  question  later. 

Persistent  and  severe  disease  of  the  bile-passages  may  develop 
out  of  the  mild  cases,  though,  be  it  remembered  always,  that  severe 
disease  is  the  exception.  Few  of  the  "bilious"  become  victims  of 
advanced  bile-passage  disease.  Another  class  of  cases  in  which  opera- 
tion may  be  avoided  is  that  in  which  an  attack  of  gall-stone  colic  passes 
and  does  not  return,  but  leaves  dyspeptic  symptoms  behind.  In  such 
cases  internal  treatment  is  indicated. 

Again,  in  the  case  of  acute  symptoms  with  pain,  icteiiis,  and  obvious 
closure  by  a  stone  of  the  common  duct,  it  is  best  to  delay  operation, 
waiting  for  the  severity  of  the  attack  to  subside.  Then  there  is  a  goodly 
number  of  cases  of  bile-duct  inflammation — cholangitis  and  cholecysti- 


THE    BILE-PASSAGES  171 

tis— which  should  be  let  alone.  They,  too,  subside,  generally  without 
surgical  treatment,  though  the  persistent  symptoms  and  their  increas- 
ing severity  rarely  may  lead  to  the  need  of  an  operation. 

Besides  the  great  class  of  cases  which  are  treated  by  internal  mea- 
sures, there  is  a  small  class  which  demands  operation  inevitably.  Writers 
have  divided  this  class  into'  ''calculus  diseases"  and  "inflammatory 
diseases."  You  cannot  so  divide  them,  for  you  cannot  possibly 
always  tell  the  inflammatory  diseases  from  those  which  produce  calculi; 
and  we  have  seen,  moreover,  that  all  are  inflammatory,  strictly  speak- 
ing. The  small  class  of  operative  cases  is  the  class  in  which  the  disease 
is  advanced,  in  which  a  persistent  inflammatoiy  action  goes  on,  with  or 
without  the  presence  of  irritating  stones. 

The  symptoms  of  pronounced  disease  of  the  bile-passages  are,  first 
and  most  important,  recurring  attacks  of  pain^ — pain  of  a  cutting, 
excruciating  character — probably  the  most  severe  form  of  pain  known, 
coming  on  unexpectedly,  often  in  the  night,  quickty  working  up  to  an 
intense  agony,  persisting  for  hours,  subsiding  gradually  or  suddenly, 
the  manner  of  subsidence  depending  upon  whether  a  stone  retreats  into 
the  ducts  or  escapes  from  them  into  the  intestine.  The  pain  of  hepatic 
colic  is  located  in  the  right  hypochondrium  or  epigastrium.  It  may 
radiate  to  the  right  shoulder-blade  or  into  the  back.  Pain  is  associated 
with  tenderness,  often  exquisite,  at  the  ninth  costal  margin  on  the 
right,  or  along  the  course  of  the  passages.  Sometimes  tenderness  is 
greatest  at  Robson's  point.  Sometimes  pressure  one  inch  to  the  right 
of  the  navel  will  elicit  pain,  indicating  adhesions  about  the  bile-passages. 

Jaundice  is  a  classic  symptom  of  bile-duct  disease.  When  present, 
it  is  characteristic,  but  it  is  not  often  present.  Jaundice  indicates  some 
obstruction  in  the  common  duct  or  hepatic  duct^obstmction  backing 
up  the  bile  into  the  liver.  Such  obstruction  may  be  due  to  inflamma- 
tory closure  of  the  ducts,  to  the  presence  of  calculi  in  the  common  or 
hepatic  duct,  to  a  neoplasm  pressing  upon  the  passages  and  occluding 
them,  or  to  the  pressure  from  without  the  passages  of  some  mass. 

You  must  look  for  sundry  other  symptoms  indicative  of  disturbance 
in  the  bile-passages — fever,  suggesting  an  acute  inflammation;  an 
abnormally  rapid  or  abnormally  slow  pulse;  bile-stained  urine,  clay- 
colored  stools,  and,  on  examining  the  blood,  a  slow  coagulation  time. 
Such  is  the  description  of  an  acute  attack  of  hepatic  colic  for  which 
large  doses  of  morphin  or  a  general  anesthetic  even  may  be  necessaiy. 
These  attacks  may  come  at  varying  intervals  through  a  long  course  of 
years  (recurrent  attacks).  Between  the  attacks  the  patient  may  feel 
comparatively  well,  but  as  time  goes  on  he  is  more  and  more  Hkel}* 
to  become  the  victim  of  such  uncomfortable  chronic  dj'speptic  symp- 
toms as  I  described  when  dealing  with  the  subject  of  mild  disease  of  the 
bile-passages. 

Acute  inflammations  of  the  bile-passages  may  come  on  without 
previous  warning  or  may  complicate  the  chronic  process.  Acute  in- 
flammations take  the  form  of  cholangitis  or  cholecystitis,  and,  accord- 
ing to  their  location,  produce  various  symptoms  and  are  called  by 


172  THE    AB1)(J.MI0.\ 

various  names.  By  acute  cholancfitis  we  usually  understand  a  severe 
infection  involving  the  common  duct,  the  hepatic  duct  with  its  radicles, 
and  often  the  cystic  duct  and  gall-bladder.  'Jhe  jxitient  V)ecomes  ex- 
tremely ill  in  a  few  days;  his  temperature  is  high,  his  pulse  rapid;  he 
appears  dusky,  with  anxious  face;  there  is  complete  loss  of  appetite; 
sometimes  there  are  nausea  and  vomiting;  the  tongue  is  red  and  cracked. 
There  are  tluU  pain  and  extreme  tenderness  over  the  bile-passages; 
the  liver  may  be  slightly  enlarged,  and  there  may  be  icterus.  The  pic- 
ture is  one  of  an  acute  systemic  infection,  with  a  locaHzed  inflammatory 
process  in  the  right  upper  abdominal  quadrant. 

Acute  cholecystitis  presents  many  of  the  features  of  acute  cholangitis, 
except  that  commonly  the  symptoms  are  less  severe  and  icterus  is 


Fig.  93. — Outline  of  enlarged  gall-bladder. 

absent.  A  special  feature  of  cholecystitis  is  an  enlargement  of  the  gall- 
bladder, due  to  inflammatory  obstruction  of  the  C3'stic  duct.  The  gall- 
bladder becomes  palpable,  and,  assuming  a  pear-shaped  outline,  may 
extend  downward  as  far  as  the  navel  even.  It  is  distended  with  bile- 
stained  mucus  or  mucopus. 

There  is  no  need  of  going  into  the  various  complicating  conditions 
associated  wdth  these  bile-duct  diseases.  The  complications  are  similar 
to  the  late  complications  of  extensive  gastric  ulcer,  and  are  due  to  the 
spread  of  inflammation  from  the  bile-passages  so  as  to  involve  adjacent 
organs.  The  ducts  may  become  stenosed,  thickened,  and  crippled. 
They  may  become  distended  above  cicatricial  strictures.  The  gall- 
bladder may  become  thickened  and  contracted  almost  to  obliteration; 


THE   BILE-PASSAGES  173 

fistulous  openings  may  connoct  it  with  neighboring  organs;  extensive 
localized  peritonitis  with  numerous  complicated  adhesions  may  result, 
and  the  functions  of  all  the  organs  implicated  may  become  seriously 
deranged.  Always,  in  considering  disease  of  the  bile-passages,  the 
surgeon  must  remember  that  close  similarity  of  the  symptoms  of  such 
disease  with  the  symptoms  of  duodenal  ulcer.  Furthermore,  when 
operating  for  bile-passage  disease,  always  examine  the  duodenum. 

Operative  Treatment.— There  are  three  reasons  for  operating  on 
the  bile-passages :  First,  for  frequent  and  recurring  biliary  colic  without 
jaundice,  with  or  without  enlargement  of  the  gall-bladder.  That  is 
the  condition  for  which  we  most  commonly  operate,  and  we  expect  to 
find  stones  in  the  gall-bladder.  If  the  attack  is  associated  with  jaundice, 
we  operate  and  expect  to  find  stones  in  the  common  duct  as  well. 

In  a  second  operative  class  is  a  group  of  cases  in  which  the  inflam- 
matory symptoms  are  the  more  apparent;  that  is  to  say,  when  there  is 
enlargement  of  the  gall-bladder  without  jaundice,  and  with  or  without 
pain;  with  fever,  tenderness,  and  general  constitutional  disturbance. 
This  situation  probably  is  due  to  some  obstruction  of  the  cystic  duct, 
and  a  resulting  backing  up  of  bile-stained  mucus  or  pus  into  the  gall- 
bladder. When  we  suspect  a  phlegmonous  cholecystitis  or  gangrene, 
a  rupture  of  the  gall-bladder,  or  an  infective  or  suppurative  process,  we 
must  operate. 

The  third  reason  for  operating  is  that  we  suspect  an  involvement  of 
other  organs  or  of  the  tissues  outside  of  the  bile-passages — peritonitis, 
painful  adhesions,  abscess,  and  fistulse.  We  must  operate  also  for  trau- 
matic lesions  of  the  bile-passages,  stabs,  shot-wounds,  and  for  primary 
tumors  of  the  gall-bladder,  provided  there  be  no  metastasis. 

Cancer  of  the  bile-passages  is  not  uncommon.  It  may  be  primar}^ 
or  secondary.  When  secondary,  it  is  practically  outside  the  field  of 
operative  measures,  but  primary  cancer  sometimes  may  be  removed, 
and,  even  when  it  is  not  removable,  the  patient's  symptoms  may  be 
relieved  by  some  palliative  operation.  The  cause  of  cancer  of  the  bile- 
passages  and  its  relation  to  gall-stones  is  highly  interesting.  You  will 
find  gall-stones  present  in  nearly  all  cases  of  primary  cancer  of  the 
bile-passages,  w-hereas  they  are  infrequently  present  in  secondary 
cancer,  so  that  we  have  come  to  believe  that  there  is  a  distinct  relation 
between  gall-stones  and  primary  cancer;  that  the  long-continued  irritat- 
ing presence  of  gall-stones  is  the  important  causative  factor  in  the 
production  of  primary  cancer.  For  this  reason,  if  for  no  other,  as  I 
stated  before,  it  is  wise  alw^ays  to  remove  well-established  and  persistent 
gall-stones. 

It  is  not  easy  to  make  a  diagnosis  of  cancer  of  the  bile-passages.  In 
its  early  stages  cancer  simulates  inflammatory  disease.  It  causes  more 
or  less  pain;  it  may  cause  jaundice,  and  it  is  associated  with  various 
dyspeptic  symptoms.  Its  presence  becomes  obvious  when  a  tumor 
can  be  felt.  Courvoisier's  law  is  sometimes  of  value  in  determining 
the  presence  of  cancer,  and  that  law  amounts  to  this:  if  you  feel  a 
distended  gall-bladder,  assume  that  the  distention  is  due  to  stones  in 


174  THK    AHDOMKX 

the  duct  or  to  cancerous  obstruction  of  the  duct.  'J'hc  distention  from 
stones  is  transient;  the  ilistention  fioni  cancer  is  jHr.si.stent.  Occa- 
sionally I  have  found  this  law  valuable,  but  observe  that  it  does  not 
account  for  gall-bladder  distention  due  to  swelling  of  the  mucosa  of  the 
ducts  or  to  cicatricial  obstruction  of  the  ducts. 

Technic. — There  is  a  mass  of  writing,  luminous  and  confusing,  m 
regard  to  methods  of  ojjerating  for  disease  of  the  bile-passages,  but 
I  believe  the  reader  will  gain  a  fairly  clear  perception  of  how  he  should 
operate  if  he  will  observe  three  laws.  These  laws  are  founded  upon 
the  analogy  between  bile-passage  disease  and  inflammation  elsewhere. 
If  you  are  dealing  with  a  palmar  abscess,  you  open  it,  remove  dis- 
organized tissue,  and  drain  it.     So  in  operating  upon  the  bile-passages: 

1.  Remove  stones. 

2.  Remove,  so  far  as  possible,  all  disorganized,  degenerated,  and 
permanentl}^  crippled  tissue. 

3.  Drain. 

In  special  cases  the  emergency  of  the  condition  and  the  intelligence 
of  the  operator  will  cause  him  to  amend  or  to  depart  from  these  rules, 
but  they  are  applicable  in  the  great  majority  of  cases. 

The  special  problem  which  commonly  confronts  the  surgeon  is, 
w^hether  to  perform  cholecystostomy  (gall-bladder  drainage)  or  cholecys- 
tectomy (removal  of  the  gall-blaclder) ,  and  men  liave  advocated  one 
measure  or  the  other  according  to  their  convictions  regarding  the 
mortality  and  permanence  of  cure  with  one  or  the  other  maneuver. 

It  is  needless  here  to  discuss  again  this  much-debated  question, 
because  the  indications  for  either  cholecystostomy  or  cholecystectomy 
are  reasonably  clear  if  you  observe  our  three  cardinal  mles.  For 
example:  perform  cholecystostomy — 

(a)  When  the  gall-bladder  and  ducts,  though  containing  stones,  are 
not  crippled  by  inflammation — that  is,  when  they  are  not  markedly 
stenosed,  thickened,  twisted,  or  contracted. 

(6)  When  acute  inflammation  exists,  with  or  without  the  presence 
of  stones.     Acute  inflammation  demands  thorough  drainage. 

(c)  When  the  common  duct  is  obstructed  by  unremovable  mahg-nant 
disease. 

Class  (a)  is  the  largest  of  all.  Class  (6)  furnishes  a  great  variety  of 
cases  suitable  for  cholecystostomy.  It  is  a  complicated  class,  and,  if 
you  choose,  you  may  call  it  the  inflammator}^  class  and  may  include  in 
it  empyema  of  the  gall-bladder;  chronic  catarrh  of  the  gall-bladder  and 
ducts;  obstruction  by  hydatids;  hydrops  of  the  gall-bladder  (not  due 
to  stricture  of  the  cystic  duct);  and  certain  cases  of  phlegmonous 
cholecystitis  accompanied  by  great  prostration. 

As  for  class  (c),  it  must  be  obvious  that  with  an  obstructive  jaundice, 
due  to  tumor  occluding  the  ducts,  a  cholecystostomy  is  essential  for 
permanent  drainage. 

Cholecystectomy  is  probably  no  more  dangerous  than  cholecystostomy 
if  it  be  performed  for  such  simple  conditions  as  are  demonstrated  in 
class  (a) ;  but,  as  a  matter  of  fact,  cholecystectomy  is  employed  in  more 


THE    BILE-PASSAGES 


175 


serious  conditions.     There  are  two  important  indications  for  cliolecys- 
tectoniy : 

(d)  Disease  crippling  the  cystic  duct. 

(e)  Disease  crippling  the  gall-bladder. 

.These  two — (d)  and  (e) — often  are  interdependent,  and  are  fre- 
quently present  together.  We  perform  cholecystectomy  when  the 
cystic  duct  is  crippled,  because  cholecystostomy,  in  that  case,  would 
not  drain  properly  the  ducts,  and  would  leave  a  gall-bladder  subject 
to  subsequent  disease.  For  much  the  same  reason  we  remove  a  gall- 
bladder when  it  is  crippled,  because  leaving  it  would  mean  leaving  a 
nidus  for  future  trouble. 


Fig.  94. — Position  of  patient  for  operation  on  liver  and  bile-passages. 

Classes  (d)  and  (e)  are  wont  to  be  concerned  with  further  advanced 
and  complicating  disease,  such  as  fistulse  and  adhesions  involving  other 
organs. 

Here  are  certain  words  which  demand  definition.  Cholecystendysis 
is  an  antiquated  procedure.  It  means  opening  the  gall-bladder,  re- 
moving its  stones,  and  sewing  it  up  again.  This  is  dangerous  and  un- 
certain, for  leakage  may  occur.  Choledochotomy  and  choledocholithotomij 
mean  opening  the  common  duct  and  removing  stones.  Cholecystenter- 
ostomy  means  forming  an  anastomosis  between  the  gall-bladder  and 
the  bowel.  I  have  found  this  last  operation  useful  in  the  case  of  per- 
manent obstruction  of  the  common  duct  or  cicatricial  stenosis  by 
mahgnant  disease,  .pancreatic  disease,  or  cicatricial  obstruction.  It 
should  not  be  done  if  the  obstruction  can  be  removed,  or  in  malignant 
disease  of  the  pancreas  with  gall-bladder  distention  when  the  patient 
is  extremely  reduced.  In  such  a  case  perform  cholecystostomy.  Nor 
should  cholecystenterostomy  be  performed  when  the  gall-bladder  is 
contracted  and  disorganized,  or  when  the  cystic  duct  is  crippled  or 


176 


THE    AI'.IXXMKN 


occluded.  Cholcdochenivrosiottnj  is  a  subst  itutc  for  cholccystenterostomy, 
and  means  uniting  by  anastomosis  the  common  duct  with  the  intestine. 
When  doing  either  of  these  two  last  operations,  in  the  case  of  malignant 
disease  of  the  bile-passages,  the  anastomosis  had  best  be  made  with  the 
transverse  colon. 


b^ 


Fig.  95. ^Incision  for  operation  on  the  liver  and  bilc-pas.';ages. 

The  detailed  technic  of  operating  upon  the  bile-])assages  need  not 
detain  us  here.'     Do  not  operate  hastily  on  ]:)atients  Avith  long-standing 

1 1  have  described  the  technic  in  "  Surgical  Aspects  of  Digestive  Disorders,"  and 
also  refer  the  reader  to  the  books  of  Jacobson,  Binnic,  Brj'ant,  Bickham,  Moynihan, 
Kocher,  and  the  large  systems  of  surgery. 


THIO    HILIO-I'ASSAGES 


177 


jaundice,  for  their  blood-coagulation  time  is  slow.     This  may  be  rom- 
etlied,  however,  by  giving  large   doses  of  calcium   chlorid— 30  grains 
three  times  daily  for  three  days  befoi-c  opei-ation  and  afterward  60 
grams   by   the  rectum   three   times   daily.     These   jaundiced   patients 
sometnnes  bleed,  by  persistent  oozing,  after  the  operation,  and  may 
die  of  such  hemorrhage  unless  the  coagulation  time  be  shortened.     A 
hard  pillow  or  movable  support,  such  as  Lilienthal  describes,  should  be 
put  under  the  back  of  the  patient  before  operation,  so  as  to  throw  up 
and  forward  the  deep  parts  of  the  field.     An  excellent  incision  is  that 
splitting  the  right  rectus  muscle.     The  cut  may  be  carried  up  to  the 
xiphoid  cartilage  and  as  low  as  required.     By  carefully  packing  off 
the  neighboring  viscera  with  gauze,  the 
bile-ducts    may   now   be   brought    into 
view,  and  may  be  handled  readily  un- 
less there  be  extensive  adhesions.     Be- 
fore   proceeding    further,    neighboring 
organs  should  be  examined  carefully  in 
order  to  ascertain  complicating  disease. 
If  one  decides  on   cholecystostomy,  sep- 
arate the  gall-bladder  from  the  liver; 
draw  it  to  the  surface;  pack  it  off;  as- 
pirate off  the  contained  fluid;  open  the 
gall-bladder;    remove   the   stones  with 
forceps    or   scoop;    palpate    the    ducts 
throughout,  removing  any  stones  they 
contain;   tie  into  the  gall-bladder  with 
catgut    a    rubber    drainage-tube,    and 
drop    back    the   gall-bladder   into   the 
abdomen,    leaving    the    tube    guarded 
with    one    or   two    light    gauze    wicks. 
Bring  the  drainage-tube  and  wicks  out 
through  a  stab-wound  in  the  abdom- 
inal wall,    1   or  2  inches  to   the  right 
of  the  long  incision,  and  sew  up  the 
incision  tight.      Thus   you  will    avoid 
subsequent   hernia.     The   drainage-tube    outside   the   dressing  is   led 
down  into  a  receiving  bottle  attached  to  the  binder  or  to  the  side  of  the 
bed.     The  wound  is  dressed  in  the  ordinary  fashion.     Bile  should  drain 
copiously  as  long  as  the  tube  remains  in  place.     The  tube  should  be 
removed  at  the  end  of  fourteen  days,  after  which  the  resulting  sinus  will 
close  permanently  in  a  day  or  two. 

Cholecystectomy  is  not  a  difficult  operation,  but  its  difficulties  have 
been  magnified  by  writers.  Open  the  abdomen  as  already  described, 
isolate  the  gall-bladder,  draw  it  up  as  far  as  possible,  open  it,  and  re- 
move all  accessible  stones;  secure  the  cystic  duct  with  a  hemostat  near 
the  common  duct;  isolate  and  secure  the  cystic  artery,  cut  away  the 
gall-bladder,  and  tie  the  cystic  stump.  Provide  for  drainage  of  the 
stump,  because  occasionally  its  ligature  gives  way,  allowing  septic  bile 

12 


Fig.  96. — Catgut  purse-string 
suture  for  compressing  the  walls  of 
the  gall-bladder  tightly  on  a 
dressed  tube.  J.  E.  Summer's 
adaptation  of  Dawbarn's  method 
to  cholecystostomy  (Mayo  in 
Keen's  Surgery). 


178 


THK    AUDOMEN 


to  escape.  In  order  to  di'aiii  the  stump,  stitch  into  it,  with  No.  00  phiin 
catjiut,  a  rubber  tube  surrounded  with  gauze  and  led  out  through  a 
stab-wound.  In  from  six  to  ten  days  the  catgut  will  be  absorbed,  when 
the  drain  may  be  withdrawn,  leaving  a  fistulous  tract  which  heals 
spontaneously. 

The  simple  maneuvers  already  described  do  not  explain  or  account 
for  the  treatment  of  such  complications  as  numerous  stones  in  the  ducts, 
stone  in  the  ampulla  of  Vater,  adhesions,  Jistulce,  and  malignant  disease. 
Numerous  stones  in  the  ducts  are  sought  by  palpation  and  by  probing. 
If  they  are  long  present,  the  ducts  becomes  so  much  dilated  as  easily  to 
admit  a  finger  for  exploration.  If  you  are  convinced  of  their  pix^sencc, 
you  may  remove  them  by  pushing  them  up  into  the  cystic  duct,  by  cut- 
ting down  upon  them  through  the  common  duct,  or,  sometimes,  in  the 
case  of  stones  in  the  hepatic  duct,  by  fastening  a  drainage-tube  into  the 


Fig.  97.— Holding  purse-string  while  inverting  cut 
margins  of  gall-bladder  opening  (Mayo  in  Keen's  Sur- 
gery). 


Fig.  98. — Purse-string 
suture  tied  (Mayo  in  Keen's. 
Surgery). 


latter  and  leaving  it  in  place,  when,  in  the  course  of  time,  stones  will 
escape  through  it  or  through  its  tract  after  its  removal.  Sometimes  it  is 
necessary  to  perform  a  secondary  operation  for  the  removal  of  stones 
at  the  time  of  withdrawing  the  hepatic  tube. 

Stones  in  the  ampulla  of  Vater  may  be  removed  by  freeing  the  duo- 
denum, turning  it  over  on  the  stomach,  and  opening  the  common  duct 
from  behind;  or,  better,  one  may  approach  the  ampulla  by  oj^ening 
through  the  duodenum  from  the  front.  The  duodenum,  after  being  thus 
opened,  must  be  stitched  up.  I  prefer  this  latter  method  of  approach: 
it  is  easy  and  direct,  and  involves  no  difficult  dissection  or  the  tearing 
up  of  adhesions. 

When  the  ducts  are  opened  for  the  removal  of  stones,  the  incision 
need  not  be  stitched  up.  Abundant  gauze  drainage  insures  against 
infection,  and  the  ducts  always  heal  readily. 


THE    BILE-PASSAGES  179 

Extensive  adhesions  about  the  bile-passages  must  be  broken  up 
when  the  adhesions  interfere  with  the  proper  removal  of  stones,  or  when 
they  cause  serious  crippling  of  organs,  but  it  is  not  wise  always  to  break 
up  fistukr^  unless  it  is  evident  that  their  presence  will  involve  future  pain 
and  invalidism. 

Primary  cancer  of  the  bile-passages  may  be  excised  in  a  few  rare 
instances,  care  being  taken  to  provide  for  proper  and  physiologic  biliary 
drainage,  if  necessary,  through  an  anastomosis  between  the  gall-bladder 
and  the  bowel.  In  most  cases,  however,  when  cancer  is  present,  some 
palliative  operation  only  is  permissible— cholecijstostomy  or  cholecystenter- 
ostomy. 

The  reader  will  observe  that  I  have  adhered  throughout  these  para- 
graphs to  our  three  cardinal  rules — always  removing  stones  and  crippled 


Fig.  99.— Cholecystduodenostomy.     Circle  sutures  introduced  and  incisions  made 
(Mayo  in  Keen's  Surgery). 

and  disorganized  tissue,  when  possible,  and  always  draining  the  deep 
field. 

Surgeons  have  debated  the  wisdom  of  removing  gall-stones  acci- 
dentally discovered  in  the  course  of  some  other  abdominal  operation — 
gastro-enterostomy,  for  instance.  I  believe  that  one  should  always 
remove  gall-stones  when  the  abdomen  is  opened  for  any  purpose,  pro- 
vided the  patient's  strength  will  permit  this  prolonged  operation. 

We  may  not  close  our  consideration  of  disease  of  the  bile-passages 
without  reflecting  again  upon  the  frequent  elusiveness  of  the  subject. 
I  doubt  if  there  is  any  series  of  ailments  to  which  the  organs  of  the  body 
are  subjected  so  frequently  secondary  to,  and  so  frequently  confused  with, 
remote  disease,  as  well  as  with  neurotic  phenomena,  as  are  the  diseases 
of  the  bile-passages.  The  following  brief  report  of  a  case  not  yet 
completed  is  illuminating  and  instructive:    The  patient,  a  woman  of 


180  THE    A]5I)()MKX 

thirty,  in  fair  health,  had  suh'ered  for  .sonic  ton  months  with  monthly 
recurring  attacks  of  pain  in  the  region  of  the  gall-bladder.  The  pain 
was  often  agonizuig,  and  lasted  for  from  twelve  to  foity-eight  hours. 
Between  attacks  the  region  of  the  gall-bladder  was  tender,  and  during 
the  attacks  the  pain  radiated  to  the  right  shoulder.  There  was  no 
jaundice,  but  this  patient,  whom  I  saw  several  times  in  consultation, 
seemed  to  be  undoubtedly  the  victim  of  gall-stone  disease.  Her  only 
other  physical  ailments  were  an  obstinate  and  life-long  consti])ation 
and  pronounced  chronic  hemorrhoids.  In  1902  this  patient  went  to 
live  in  another  cit}',  and  came  under  the  care  of  a  surgeon  of  excellent 
reputation  and  ability.  He  operated  on  her  for  gall-stones  and  found 
absolutely  nothing  abnormal,  as  he  told  me  afterward.  He  drained 
the  gall-bladder  for  three  weeks,  after  which  there  was  a  remission  of 
severe  S3'mptonvs  for  about  a  year. 

In  1903  the  symptoms  of  gall-stone  colic  returned  and  persisted 
for  two  years.  The  patient  was  in  constant  fear  of  the  attacks,  and 
led  the  life  of  an  invalid. 

In  1904  she  consulted  an  internist,  who  convinced  himself  that  the 
disease  and  her  sufferings  were  not  due  to  a  bile-passage  disorder,  but 
to  a  gastric  hyperchlorh3alria  with  periodic  pyloric  spasm.  Acting  on 
that  conviction,  he  put  her  on  a  long  and  thorough  course  of  antacids 
— especially  sodium  bicarbonate.  She  was  greatly  relieved  for  a  year, 
when,  becoming  careless  of  treatment,  her  symptoms  began  to  recur. 
At  that  time — 1905 — she  happened  to  be  in  Boston,  where  she  con- 
sulted another  internist,  who  told  her  that  her  undoubted  hyperchlor- 
hydria  and  pyloric  spasm  were  due  primarily  to  tonic  spasm  of  the 
sphincter  ani,  which  resulted  in  constipation,  improper  drainage  of  the 
intestines,  and  a  series  of  chemical  changes  resulting  refiexly  in  her 
gastric  irritation.  This  rather  unsatisfactory  explanation  of  her  condi- 
tion was  accepted,  and  she  had  the  sphincter  ani  dilated  in  accordance 
with  the  advice  of  this  physician.  There  followed  for  four  years  relief 
of  all  her  symptoms.  The  constipation  was  cured;  the  hemorrhoids 
disappeared;  the  dyspepsia  and  the  epigastric  pain  and  distress  were 
relieved  entirely. 

The  reader  will  see  at  once  that  this  case  is  incomplete  and  unsatis- 
factory. I  have  cjuoted  it  merely  as  an  interesting  object-lesson,  as 
demonstrating  the  difficulties  of  diagnosis  and  the  errors  of  treatment 
often  seen  in  cases  of  disease  of  the  digestive  organs. 


CHAPTER  VI 

THE  PANCREAS  AND  SPLEEN 

The  Pancreas 

The  pancreas  is  a  digestive  organ  so  closely  associated  with  the  liver 
and  bile-passages  that  we  must  think  of  it  anatomically  and  surgically 
as  a  part  of  the  same  apparatus.  The  two  are  upon  twigs  of  the  same 
bough,  which  is  implanted  in  the  duodenum.  Unfortunately,  injury 
and  disease  of  the  pancreas  are  more  common  than  we  used  to  think — 
unfortunatel}'",  because  the  organ  is  not  easily  accessible  and  because 
operations  upon  it  are  difficult  and  hazardous.  Sometimes  one  may 
treat  it  surgicaUy  through  drainage  of  the  gall-bladder,  as  I  shall  ex- 
plain. 

Obsei^e  that  the  pancreas  is  so  deeply  placed  behind  the  stomach 
as  rarely  to  be  injured;  that  it  is  between  4  and  5  inches  long;  that 
its  head  Hes  partiaUy  surrounded  by  the  duodenum;  that  the  aorta, 
vena  cava,  and  portal  vein  he  behind  it;  that  it  has  two  ducts  (Wirsung 
and  Santorini)  which  viay  open  separately  into  the  duodenum,  and 
that  it  is  nourished  by  branches  of  the  splenic  arteiy,  which  lies  im- 
mediately above  it. 

Of  late  it  has  become  the  fashion  to  discuss  operations  on  the  pan- 
creas, but  in  practice  you  will  find  that,  with  the  exception  of  two  of  its 
diseases, — chronic  i^ancreatitis  and  cysts,^ — it  rarely  concerns  the  surgeon. 

In  general  terms  one  may  divide  diseases  of  the  pancreas  into — 

(a)   Inflammations. 

(6)   Tumors  (cysts). 

(c)    Injuries. 

Of  the  three,  inflammations  are  of  the  most  importance  surgicaUy. 

INFLAMMATIONS  OF  THE  PANCREAS— PANCREATITIS 

Pancreatitis  ma}'-  be  acute,  chronic,  and  sometimes  subacute;  while 
writers  use  sundry  other  terms,  such  as  hemorrhagic,  suppurative,  gan- 
grenous. 

Acute  pancreatitis  may  arise  from  a  pancreatic  apoplex}-  or  from 
an  infection,  but  whatever  the  cause,  there  is  nearly  always  hemorrhage 
within  the  gland;    hence  the  term,  hemorrhagic  pancreatitis. 

Pancreatic  apoplexy  is  an  overwhelming  disease,  and  usually  ends 
rapidly  in  death.  The  hemorrhage  occurs  first;  tissue  is  destroyed; 
the  pancreatic  secretion,  consequently  outpoured,  causes  a  necrosis; 
more  hemorrhage  results,  and  the  patient  quickly  succumbs.     If  the 

181 


182 


THE    AH DOMEX 


acute  pancreatitis  is  from  an  infection,  it  may  be  clue  to  an  invasion  of 
septic  material  through  the  duct  of  A\'irsung.  Opie's  familiar  exi)lana- 
tion  is  often  the  con-ect  one,  as  I  have  seen  in  2  of  my  own  cases  at 
operation:  A  small  gall-stone  comes  down  through  the  bile-ducts  and 
lodges  at  the  outlet  of  the  ampulla  of  Vater.  Then  bile  fails  to  get  out 
into  the  intestine,  but  is  shunted  off  into  the  pancreatic  duct,  and  sets 


Fig.  ICO. — Acute  hemorrhagic  pancreatitis  (Cser). 

up  an  acute  infection  of  the  gland.  This  is  one  of  the  interesting  and 
important  relations  between  bile-duct  and  pancreatic  disease.  This 
infective  form  of  acute  pancreatitis,  though  grave,  is  not  so  immediately 
lethal  as  is  that  due  to  pancreatic  apoplexy.  It  sets  up  a  veiy  active 
inflammation,  however,  with  hemorrhage,  spreading  infection,  gangrene, 
suppuration.  Some  cases  may  run  on  into  a 
subacute  condition,  and  in  nearly  all  cases  a 
disseminated  fat-necrosis  will  be  found  through- 
out the  abdomen,  and  especially  in  the  region  of 
the  pancreas,  at  autopsy  or  operation. 

The  symptoms  of  acute  pancreatitis  are  seen 
in  i)ersons  of  previous  presumably  good  health. 
The  symptoms  are  immediately  ovenvhelming: 
vomiting,  collapse,  with  a  rapid,  thi-eady  pulse, 
clammy  skin,  and  cold  exti'emities.  Quickly 
there  supervene  symptoms  of  peri1;onitis.  Often 
the  condition  is  mistaken  for  intestinal  ob- 
struction, but  the  constipation  is  not  absolute, 
and  there  appears  within  twenty-four  hours  a 
circumscribed  tympanitic  or  resistant  swelling  in 
the  epigastrium.  These  attacks  run  a  vaiying  course.  Some  patients 
die  within  forty-eight  hours  or  some  live  for  several  weeks,  the  pan- 
creas becoming  disorganized.  There  is  fever,  due  to  suppuration,  and 
there  is  a  wide-spread  fat  necrosis;  other  patients  form  a  small  third 
class  who  may  live  a  long  time  and  may  suffer  repeated  attacks  of 
acute  pancreatitis,   which    produce  sclerosis  of    the   pancreas.      The 


Fig.  101. — Stone  in  am 
pulla  of  Vater. 


INFLA.MMATIOXS   OF   THE   PANCREAS — PANCREATITIS  183 

cases  of  subacute  pancreatitis,  so  called,  are  merely  modifications  of  this 
third  class.  Abscess  is  a  common  outcome;  the  attacks  come  on  with 
remissions;  there  is  albumin  in  the  urine,  sometimes  sugar,  and  rarely- 
fat.  Such  patients  usually  die  of  the  disease  eventually,  though  spon- 
taneous recoveries  are  known,  with  sloughing  of  the  pancreas  and  its 
escape  through  perforation  into  the  stomach  or  intestine. 

The  treatment  of  all  forms  of  acute  pancreatitis  is  strictly  operative, 
so  far  as  any  treatment  can  be  employed.  But  do  not  rashly  operate 
upon  first  seeing  a  patient  in  the  profound  collapse  of  pancreatic  apo- 
plexy, else  you  will  but  hasten  his  death.  Wait  a  few  hours  in  the 
hope  that  he  may  rallj-,  for  the  hemorrhage  is  not  persistent,  and 
stimulants  and  opium  may  alleviate  the  symptoms.  Operate  to  re- 
move the  offending  focus.  Open  the  abdomen  in  the  median  line, 
tear  through  the  gastrocolic  omentum,  expose  the  damaged  pancreas, 
which  will  be  found  engorged,  bloody  looking,  dark,  surrounded  by  a 
hemorrhagic  exudate  and  an  area  of  fat-necrosis.  Scoop  out  detritus, 
and  drain  with  rubber  tubing  and  gauze  wicks.  Investigate  the  condi- 
tion of  the  common  bile-duct  and  of  the  ampulla.  Observe  that  a 
general  peritonitis  already  may  have  become  established,  so  that  you 
will  find  it  necessary  to  wash  out  the  abdominal  cavity  with  a  hot 
saline  solution,  and  to  drain  the  pelvis  through  a  tube  inserted  above 
the  pubes.  Conduct  the  after-treatment  carefully;  employ  Fowler's 
position,  cleansing  enemata,  and  nutrient  enemata;  normal  saline  solu- 
tion in  the  rectum,  in  the  veins,  or  under  the  skin;  strychnin,  gastric  lav- 
age; nothing  whatever  by  mouth  for  forty-eight  hours — then  begin  with 
careful  dieting  and  saline  laxatives. 

The  less  severe  or  subacute  cases  lend  themselves  more  hopefully  to 
treatment  than  do  cases  which  have  gone  on  to  suppuration,  extensive 
necrosis,  and  gangrene.  In  such  less  severe  cases  drainage  again  is 
our  one  expedient.  Such  drainage  may  be  instituted  from  the  front 
through  the  gastrocolic  omentum,  as  already  described  (sometimes 
through  the  gastrohepatic  omentum  above  the  stomach,  if  that  organ 
is  prolapsed) ;  or  one  may  approach  the  pancreas  through  the  back,  on 
the  left,  thus  securing  dependent  drainage.  At  the  best,  acute  pan- 
creatitis is  extremely  fatal,  and  with  a  proper  operation  even  we  can- 
not look  for  a  death-rate  much  below  50  per  cent. 

Chronic  pancreatitis  is  commonl}'-  associated  with  disease  of  the 
bile-passages,  and  cannot  well  be  dissociated  from  it.  Indeed,  it  must 
be  regarded  as  part  of  the  same  general  process,  but  it  is  not  often 
discovered,  except  in  the  course  of  an  operation  for  gall-stones  or  at 
autopsy.  Other  causes  of  chronic  pancreatitis  are  pancreatic  calculi, 
obstructions  of  "Wirsung's  duct,  pressure  from  without,  tj-phoid  fever, 
chronic  alcoholism,  syphilis,  and  gastric  or  duodenal  ulcer.  Whether 
the  important  factor  be  bile-passage  disease  or  some  of  the  less  common 
causes,  some  form  of  occlusion  of  the  pancreatic  duct,  limiting  or  ob- 
stiTicting  completely  proper  drainage  of  the  gland,  is  the  important 
etiologic  factor  in  chronic  pancreatitis.  Such  obstmction  results  in  a 
catarrh  leading  to  a  chronic  interstitial  process,  the  evidence  of  which 


184  THE   ABDOMEN 

is  an  induration  and  enlargement  of  the  jjancreas — usually  the  head  of 
that  organ. 

The  symptonia  of  chronic  pancreatitis  are  elusive  and  various.  As 
A.  K.  Stone  has  said,  "chronic  interstitial  pancreatitis,  from  the  opera- 
tor's point  of  view,  presents  a  brilliant  series  of  liappy  blunders."  Tlie 
symptoms  point  usually  to  bile-duct  tlisease,  and  on  exj)l()ring  that  re- 
gion one  may  find  no  gall-stones  presc^it,  but  an  enlarged  indurated  head 
of  the  pancreas  constricting  the  common  duct,  which  passes  through 
it,  thus  giving  rise  to  jaundice.  That  is  the  common  symptom — jaun- 
dice. There  may  be  a  low  intermittent  fever  and  possibly  tenderness 
in  the  epigastrium,  with  considerable  loss  of  flesh.  Sometimes  there 
is  fulness  above  the  umbilicus.  Fat  and  muscle-fibers  may  be  found 
in  the  movements.  In  general,  the  picture  is  one  of  rather  constant 
epigastric  distress,  associated  with  bile-duct  disease.^ 

Treatment  will  usually  concern  itself  with  the  disease  of  the  bile- 
passages.  If,  on  opening  over  the  bile-passages  one  detects  a  tumor 
in  the  head  of  the  pancreas,  the  proper  procedure  is  to  drain  the  ducts 
through  cholecystostomy.  Sometimes  it  may  seem  best  to  perform 
cholecystenterostomy,  but  the  danger  of  infecting  the  gall-bladder  from 
the  intestine  renders  this  inadvisable,  as  a  rule.  It  is  usually  impos- 
sible, even  with  the  abdomen  opened,  to  distinguish  chronic  pancreati- 
tis from  cancer  of  the  head  of  the  pancreas,  but  drainage  cures  pan- 
creatitis and  does  not  affect  cancer.  I  have  been  impressed  with  the 
brilliancy  and  success  of  these  operations  in  relieving  non-malignant 
pancreatic  disease,  and  cannot  too  strongly  urge  upon  the  opei'ator 
that  he  should  examine  the  pancreas  in  all  cases  of  operation  upon  the 
bile-passages.  If  the  pancreatitis  be  due  to  pancreatic  calculi,  they 
may  be  removed  by  opening  the  duodenum  and  searching  the  duct  of 
Wirsung  through  the  ampulla.  Pancreatitis  due  to  other  rare  causes 
must  be  treated  on  the  general  principles  a])plicable  to  these  causes; 
but  in  all  cases  of  doubt  one  should  establish  drainage  of  the  bile- 
passages.^ 

TUMORS  OF  THE  PANCREAS 

Tumors  of  the  pancreas  may  be  divided,  for  practical  purposes,  into 
solid  tumors  and  cysts.  Cancer  of  the  pancreas  is  not  uncommon, 
and,  like  other  diseases  of  the  pancreas,  is  difficult  of  diagnosis.  Its 
symptoms  are  quite  similar  to  those  of  chronic  panci'catitis,  and  it  is 
often  associated  with  disease  of  the  bile-passages.  Cachexia  and  wast- 
ing accompany  it,  but  are  not  characteristic.  Rarely  aou  may  feel  the 
mass  in  a  thin-walled  abdomen.  It  cannot  be  cured,  neither  can  it 
always  be  diagnosticated  accurately,  even  when  the  abdomen  is  opened. 
If  the  surgeon  is  in  doubt  about  the  chai'acter  of  the  tumor,  he  should 
drain  the  bile-passages  in  the  hope  that  the  disease  may  prove  to  be 
non-malignant. 

1  Robson  and  Cammidge,  The  Pancreas:    Its  Surgerj'  and  Pathology,  1907. 

2  W.  J.  Mayo,  Pancreatitis  Resuhing  from  Gall-stone  Disease,  Jour.  Amer.  Med. 
Assoc.,  April  11,  1908. 


TUMORS    OF    THE    PANCREAS 


185 


Cysts  of  the  pancreas  are  the  surgeon's  own.  They  may  be 
diagnosticated,  and,  usually,  they  can  be  cured.  Under  the  term 
"cyst"  we  group  several  different  pathologic  processes,  which  may  be 
within  the  pancreatic  tissue  proper,  or  may  be  extrapancreatic,  but 
connected  with  the  gland  and  containing  pancreatic  fluid.  This  latter 
form  of  cyst  is  a  pseudocyst.  The  pancreatic  cysts  proper  are  small  and 
may  not  cause  symptoms.  Rarelj^  they  may  reach  a  great  size.  There 
are  also  found  within  the  pancreas  proliferation  cysts — adenomatous 
or  epitheliomatous,  as  well  as,  rarely,  hydatid  cysts  and  the  congenital 
cysts  of  children.     Finally,  there  is  the  pseudocyst,  which  may  develop 


Fig.  102. — Drainage  of  pancreatic  cyst. 

spontaneously  in  the  peripancreatic  tissue  or  may  be  due  to  a  heavy 
blow  or  crush. 

The  sym])toms  of  pancreatic  cyst  may  be  inconspicuous  for  a  long 
time,  until  the  tumor  becomes  so  large  as  to  press  upon  and  inter- 
fere with  the  functions  of  organs;  then  there  is  graduall}^  increasing 
pain,  with  vomiting,  malnutrition,  and  rapid  wasting.  There  may  be 
fatty  stools  or  undigested  proteid  material  in  the  discharges.  The 
bowels  are  often  loose,  and  the  pancreatic  reaction  of  Cammidge  ^  may 
be  found  in  the  urine.  But  the  important  and  confirmatory  sign  is  a 
palpable  cystic  tumor,  found  in  the  epigastrium. 

1  J.  G.  Mumford,  Surgical  Aspects  of  Digestive  Disorders,  p.  287. 


18o  THE    AI5DOAIEN 

The  treatment  of  pancroatic  cysts  is  simple  and  highly  successful — 
incision  and  drainage.  The  tumor  usually  presents  between  the 
stomach  and  transverse  colon,  though  rarely  it  may  appear  above 
the  stomach.  The  safest  operation  consists  in  evacuating  the  cyst, 
stitching  the  sac  to  the  parietal  peritoneum,  and  employing  tubular 
or  gauze  drainage.  Bear  in  mind  that  the  cyst  fluid  contains  pan- 
creatic secretion.  This  may  excoriate  the  skin,  which  nmst,  there- 
fore, frequently  be  cleaned,  and  should  be  protected  b}'  heavy  applica- 
tions of  zinc  oxid  ointment  and  rubber  protective.  A  drained  cyst 
will  heal  in  the  course  of  months,  but  the  ])atient  may  be  up  and  about 
in  three  weeks.  Sometimes  the  fistula  will  not  close  for  a  year  or  more, 
but  eventual  healing  is  almost  certain.  In  a  few  cases  operators  have 
undertaken  the  more  daring  and  radical  procedure  of  enucleating  the 
C3'st,  but  this  is  extremely  dangerous  and  unwarrantable  unless  the  sac 
be  isolated  from  the  pancreas  proper  and  connected  with  it  by  a  small 
pedicle  only.  In  such  case  the  pedicle  may  be  clamped  and  tied  off 
and  the  abdomen  closed  with  drainage. 

TRAUMATIC   INJURIES  OF  THE  PANCREAS 

Writers  will  tell  you  truly  that  the  pancreas  rarely  is  injured  by 
violence,  though  their  statistics  probably  do  not  take  into  account  those 
injuries  which  fail  to  produce  immediate  symptoms,  but  are  followed 
later  by  the  development  of  pseudocysts.  Many  injuries  to  the  pan- 
creas are  overlooked,  doubtless,  because  other  organs  are  involved  and 
because  death  frequently  supervenes.  However  all  that  may  be,  a 
severe  crushing  blow  is  required  to  damage  the  pancreas — a  blow  im- 
pinging upon  the  epigastrium  and  directed  from  before  upward  and 
backward,  grinding  the  gland  against  the  spinal  column. 

There  are  no  immediately  obvious  signs  and  symptoms  which  enable 
us  to  diagnosticate  an  injured  pancreas.  AYe  shall  see  marked  evi- 
dence of  profound  shock,  of  hemorrhage,  and  later  of  peritonitis,  all 
increasing.  Other  organs  may  be  involved,  but  if  the  damage  is  in 
the  epigastrium,  a  surgeon  should  always  explore  the  region  of  the 
pancreas. 

Operate  by  opening  through  the  middle  line  of  the  abdomen  above 
the  umbilicus.  If  time  allows,  repair  obvious  damage  to  other  organs; 
then,  if  one  suspects  a  pancreatic  lesion,  examine  the  pancreas  by 
tearing  through  the  gastrohepatic  omentum  above  the  stomach.  You 
will  often  find  extravasated  blood  and  pancreatic  fluid  in  the  lesser  sac. 
Clean  it  out.  and  see  to  it  that  this  fluid  does- not  contaminate  the  general 
cavity.  AYall  off  the  surrounding  viscera.  If  the  pancreas  is  lacerated 
or  bleeding,  repair  the  wound  with  deep  catgut  sutures  threaded  upon 
blunt  curved  needles.  Sometimes  it  is  necessar}'  to  ligate  en  masse  a 
lacerated  section  of  the  gland.  In  order  to  prevent  further  soiling  of 
the  general  cavity,  the  peritoneum  which  forms  the  posterior  part  of 
the  lesser  sac  may  be  stitched  over  the  wounded  pancreas,  but,  as  a 
general  rule,  the  surgeon  will  prefer  to  provide  thorough  and  careful 


INJURIES   OF   THE    SPLEEN  187 

drainage  by  tube  and  gauze,  with  exit  either  through  the  anterior  al)- 
doniinal  wound,  through  a  special  posterior  stab-wound,  or  through 
both. 

The  Spleen 

The  mystery  of  the  spleen  is  a  subject  of  the  most  fascinating  surgi- 
cal inquiry,  as  it  is  of  physiologic  inquiry.  Physiologically,  the  spleen 
is  unique  because  we  have  little  accurate  knowledge  of  its  functions; 
surgically,  it  is  unique  because,  when  subject  to  operation,^  we  must 
usually  remove  it  entire.  Writers  recite  8  causes,  with  certain  obvious 
exceptions,  for  its  removal— S  causes  about  which  there  is  general 
agreement:  Injury,  abscess,  tuberculosis,  cysts,  new-growths,  malarial 
enlargements,  splenic  anemia,  wandering  spleen.  Davis  ^  remarks 
truly,  "Until  the  physiology  of  an  organ  is  known,  its  pathology  is 
likely  to  be  elusive.  On  the  other  hand,  a  study  of  its  pathology  is 
often  rewarded  by  a  clearer  knowledge  of  its  physiology." 

INJURIES  OF  THE  SPLEEN 

We  have  all  seen  occasional  injuries  of  the  spleen  in  large  hospital 
practice.  They  are  not  uncommon,  but  the  symptoms  are  not  charac- 
teristic, and  the  diagnosis  is  often  obscure.  There  are  shock,  collapse, 
and  evidence  of  persistent  internal  hemorrhage.  Splenic  hemorrhage, 
like  hepatic  hemorrhage,  continues  because  there  are  few  muscle  ele- 
ments in  the  gland  to  favor  contraction  of  vessels  and  thrombus-forma- 
tion. So  the  belly  fills  with  blood.  Quickly,  fluid  in  the  flanks  is 
apparent;  there  is  a  tendency  to  vomiting,  and  there  ensues  rigidity  of 
the  abdominal  muscles,  especially  in  the  left  upper  quadrant. 

For  convenience,  Moynihan  divides  injuries  of  the  spleen  into  3 
classes:  Prolapse,  penetrating  wounds,  subcutaneous  rupture.  The 
spleen  may  prolapse  through  an  incised  wound.  If  it  can  be  properly 
cleansed,  the  surgeon  may  return  it  inside  the  abdomen  and  close  the 
wound  with  drainage.     If  it  is  torn  or  foul,  it  must  be  excised. 

Penetrating  wounds  of  the  spleen  are  generally  found  comphcated 
with  wounds  of  other  organs— the  diaphragm,  pleura,  stomach,  liver, 
kidney,  pancreas,  etc.  So  the  symptoms  are  obscure,  and  the  con- 
dition is  discovered  only  upon  opening  the  abdomen,  which  should 
be  done  in  all  cases  of  penetrating  abdominal  wounds.  If  the  splenic 
hemorrhage  is  excessive  and  the  patient  prostrated,  _  the  organ  should 
be  removed  at  once.  The  spleen  is  not  essential  to  life.  In  rare  cases 
it  may  be  possible  to  control  the  hemorrhage  by  passing  through-and- 
through  heavy  catgut,  mattress,  double  stuures,  threaded  upon  a  blunt- 
pointed  needle.  _ 

Subcutaneous  rupture  of  the  normal  spleen  is  uncommon,  ihe 
ordinary  prerequisite  for  rupture  is  a  pathologic  enlargement,  malarial 
or  some  other.  The  enlarged  spleen  of  women  in  the  last  months  of 
pregnancy   has   been   ruptured.     The   elaborate   paper   of   Lewerenz, 

1  Byron  B.  Davis,  Indications  for  the  Removal  of  the  Pathologic  Spleen,  Jour. 
Amer.  Med.  Assoc,  September  2,  1905. 


188  THE    AUDOMKN 

published  in  1900,  is  coininoiily  (luotcd  in  connection  with  tliis  subject. 
The  symptoms  of  ruptured  spleen  are  those  of  profound  shock  and 
hemorrhage,  as  I  have  described  them. 

The  treatment  of  ruj)tured  spleen  is  not  the  simple  matter  one  "would 
suppose,  from  the  statements  of  certain  writers,  who  advise  invaiiable 
splenectomy.  Hemorrhage  from  the  wounded  spleen  can  often  be 
checked  only  by  removing  the  spleen,  and  this  is  generally  the  safest 
course;  but  one  may  discriminate.  Wounds  of  the  hilus  demand 
splenectomy,  but  many  wounds  of  the  convex  border,  especially  slight 
wounds,  may  be  treated  by  a  gauze  tampon  or  by  the  crushing  and 
suturing  method  advocated  by  Senn;  that  is,  by  crushing  to  a  pulp, 
with  heavy  forceps,  the  bleeding  surfaces,  and  then  suturing  together 
the  crushed  portions. 

Splenectomy  of  the  non-adherent  spleen  is  not  difficult.  That  organ 
may  be  approached  through  an  incision  along  the  left  linea  semilunaris, 
the  opening  being  enlarged  by  a  supplementary  cut  at  right  angles  to 
the  first,  if  you  choose;  or  the  surgeon  may  open  the  abdomen  along 
the  border  of  the  ribs,  resecting  the  eighth,  ninth,  and  tenth  cartilages. 
The  pedicle  of  the  spleen,  composed  mainly  of  the  splenic  vessels,  must 
be  secured  carefully  with  several  ligatures ;  while  its  slight  attachments, 
especially  the  rather  important  phrenosplenic  ligament,  can  be  cut  away 
readily  between  ligatures.  Difficult  splenectomies  are  those  in  which 
one  encounters  the  extensive  adhesions  which  form  quickly  about  a 
damaged  or.  diseased  spleen — adhesions  which  must  be  removed  cau- 
tiously on  account  of  the  great  vascularity  of  the  parts,  especially  of  the 
spleen  itself.  These  adhesions  may  frustrate  entirel}^  attempts  at 
splenectomy.  If  the  spleen  be  once  safely  excised,  the  abdominal  in- 
cision may  be  sewed  up  tight  or  drained,  according  as  the  deep  parts  of 
the  field  are  dry  or  ooze  persistently. 

ABSCESS  AND   TUBERCULOSIS  OF  THE  SPLEEN 

Abscess  of  the  spleen  is  rare,  though  Spear,^  in  an  admirable 
paper,  maintains  that  it  is  more  common  than  we  have  supposed.  It 
is  one  of  the  complications  of  acute  infectious  diseases,  especially  of 
typhoid  and  malaria;  or  it  may  be  secondary  to  some  such  primary 
infection  as  appendicitis.  The  diagnosis  is  difficult,  and  the  absence 
of  fever  does  not  preclude  splenic  abscess.  The  abscess  may  be  single 
or  multiple.  Splenectomy  is  the  best  treatment,  though,  rareh^,  in- 
cision (splenotomy)  must  be  employed. 

Tuberculosis  of  the  spleen  may  be  a  reason  for  splenectomy,  but, 
generally,  a  tuberculosis  of  the  spleen  is  part  of  a  wide-spread  process, 
so  that  removal  of  the  gland  is  useless. 

CYSTS  OF  THE   SPLEEN 

Cysts  of  the  spleen  form  quite  another  chapter,  and,  like  cysts  of 
the  pancreas,   are  peculiarly  amenable  to  surgical  treatment.     There 
1  Walter  M.  Spear,  Abscess  of  the  Spleen,  Jour.  Amer.  Med.  Assoc.,  1902. 


SPLENIC   ENLARGEMENT  189 

are — (1)  Non-parasitic  '  and  (2)  parasitic  cysts — (a)  serous  cysts; 
blood  cysts;  lymph  cysts;  dermoid  cysts;  and  (b)  hydatid  cysts. 
The  most  common  non-parasitic  cysts  result  from  some  subcapsular 
hemorrhage.  A  considerable  literature  of  these  cysts  is  now  available, 
but  we  have  not  yet  arrived  at  a  satisfactory  means  of  diagnosis.  The 
symptoms  are  prostration,  anorexia,  wasting,  headache,  and  the  presence 
of  a  tumor  which  may  reach  to  the  pubes.      Hydatid  disease  gives  us 


Fig.  103. — Hemorrhagic  cyst  of  spleen  (Moynihan). 

the  most  common  cyst.  The  cysts  have  been  aspirated,  opened,  mar- 
supialized,  and  drained;  but  the  only  satisfactory  treatment  is  splenec- 
tomy, if  it  can  be  done. 

NEOPLASMS  OF   THE   SPLEEN 

Neoplasms  of  the  spleen  ^  are  extremely  rare.  There  have  been 
reported  a  few  cases  of  sarcoma;  fewer  still  of  cavernous  angioma,  and 
some  curiosities  of  surgery  recorded  as  fibroma,  endothelioma,  myxoma, 
and  lipoma.  Splenectomy  is  the  only  operation  which  can  be  employed 
profitably  in  dealing  with  these  growths. 

SPLENIC  ENLARGEMENT 

Malaria  is  one  of  the  commonest  causes  of  splenic  enlargement — 
an    enlargement   which   sometimes   may   necessitate   operation.     The 

1  Heinricius,  Arch.  f.  klin.  Chir.,  1904,  Ixxii,  130;  and  Charles  A.  Powers.  Ann. 
Surg.,  January,  1906. 

2  Jepson  and  Albert,  Ann.  Surg.,  1£S8,  vol.  xi,  p.  80. 


190  THK    AUDo.MKN 

cases  operated  upon  are  not  numerous,  and  few  men  have  li;ul  more 
than  one  or  two.  Bessel-Hagen's  ^  j)ai)er  i.s  frequently  (juoi cd,  for  lie 
has  collected  the  largest  number  of  cases.  The  upshot  of  this  discus- 
sion is  that,  if  an  enlarged  malarial  spleen  becomes  dislocated  and 
causes  constant  pain,  it  may  be  excised.  Some  observers  go  further  and 
assure  us  that  an  enlarged  malarial  spleen,  not  dislocated,  is  often 
the  source  of  continuous  malarial  poisoning  and  should  be  removed — 
mark'  the  proviso! — if  persistent  antimalarial  treatment  fails  to  cure. 
Splenectomy  for  malaria  should  not  be  delayed  until  marked  ascites 
has  appeared,  nor  should  the  size  of  the  splecni  modify  one's  decision 
to  operate.     Spleens  of  all  sizes  are  removed  with  equal  safety. 

Splenic  anemia,^  so-called  splenomegaly,  furnishes  the  surgeon  with 
an  interesting  problem — a  problem  needlessly  confused  through  a  fre- 
quent misuse  of  terms.  It  is  characterized  by  a  decrcnise  in  the  num- 
ber of  red  corpuscles  in  the  blood;  no  leukoc}'tosis;  primary  splenic 
hypertrophy;  hemorrhages  from  the  mucous  membranes;  progressive 
weakness;  vomiting;  diarrhea  and  bronzing  of  the  skin.  The  course 
may  run  as  long  as  fifteen  years,  or  the  patient  may  be  dead 
within  a  year.  Late  in  the  disease  there  is  hypertrophy  of  the  liver, 
with  ascites.  Particularly  must  splenic  anemia  be  distinguished  from 
splenic  leukemia,  which  is  characterized  by  a  marked  decrease  in  the 
number  of  red  corpuscles  and  an  increase  of  the  white.  Unfortunately 
for  certainty  of  diagnosis,  as  Osier  shows  in  one  case,  the  leukocytosis 
of  splenic  leukemia  may  be  slight  or  entirely  absent.  But  note  the 
important  point — myelocytes  averaging  30  per  cent,  invariably  are 
present  in  splenic  (myelogenous)  leukemia. 

The  symptoms  upon  which  we  must  base  our  diagnosis  of  splenic 
anemia  are,  therefore,  splenic  tumor,  hemorrhages,  which  may  become 
almost  fatal,  ascites,  enlargement  of  the  liver,  a  diminished  ''red  count," 
a  low  percentage  of  hemoglobin  (due  probably  to  the  hemorrhages), 
and  a  normal  or  diminished  'Svhite  count." 

Treatment. — In  a  certain  proportion  of  cases,  which  should  increase 
with  increasing  experience,  splenectomy  results  in  the  cure  of  splenic 
anemia.^  To  prove  successful,  however,  the  operation  should  be  done 
at  a  comparatively  early  stage  of  the  disease,  before  the  liver  is  enlarged 
or  the  ascites  marked. 

In  splenic  leukemia,  splenectomy  must  not  be  done.  That  one 
much-quoted  case  of  Richardson's,  which  seemed  at  first  to  contradict 
this  assertion,  died  four  years  after  the  operation,  and  uninfluenced  by 
the  operation,  as  Richardson  himself  reported.^ 

PTOSIS  OF  THE   SPLEEN 
Ptosis  of  the  spleen  is  occasionally  seen  associated  with  a  general 
visceral  ptosis;    and,  independently,  the  spleen  may  drop  or  "wander." 

1  Arch.  f.  klin.  Chir.,  1900,  vol.  Ixii. 

2  Splenic  anemia  was  described  by  Ranti  in  the  I^erlin.  klin.  Woch.,  1886. 

3  See  report  by  J.  E.  Summers,  Ann.  Surg.,  .June,  I'JOS,  p.  1006. 

4M.  H.  Richardson,  Splenectomy  for  Myelogenous  Leukemia,  Ann.  Surg., 
November,  1905. 


PTOSIS   OF   THE   SPLEEN  191 

Sometimes,  hypertroiihy  causes  the  organ  to  fall  out  of  place  by  its  own 
weight.  Sometimes  a  prolapsed  spleen  becomes  hyj^ertrophied  secon- 
darily. One  of  the  chief  dangers  of  wandering  spleen  is  that  the  pedicle 
may  become  twisted  through  ISO  or  360  degrees,  or  even  more,  with 
resulting  engorgement,  strangulation,  and  gangrene. 

^^'hcn  a  prolapsed  spleen  is  enlarged  or  has  a  twisted  pedicle,  the 
organ  must  be  excised. '  A  large  heavy  spleen  cannot  be  secured  by 
stitching  it  into  place.  But  in  the  case  of  a  normal  spleen,  splenopexy 
may  suffice  to  fix  it  permanently,  and  the  pocketing  operation  (behind 
the  diaphragmatic  peritoneum)  of  Rydygier;  the  method  of  Kouwer, 
by  tamponade;  or  Basil  Hall's  ^  method — stitching  the  lower  pole  into 
the  parietal  wound — have  proved  satisfactory.  But  in  his  zeal  for  an 
early  and  prompt  cure,  the  surgeon  must  not  neglect  conservative  and 
safe  methods.  Often  a  prolapsed  spleen,  if  not  too  large,  maj'  be 
replaced  and  may  be  held  comfortably  in  position  by  a  well-applied 
bandage,  such  as  I  shall  describe  in  the  chapter  on  Abdominal  Ptosis. 

Such  are  the  diseases  of  the  spleen  for  which  operations  may  be 
employed.  Per  contra,  we  are  agreed  that  splenectomy  is  always 
contraindicated  in  case  of  atrophic  cirrhosis  of  the  liver,  in  amyloid 
disease,  and  in  splenic  myelogenous  leukemia. 

1  Ann.  Surg.,  April,  1903. 


CHAPTER  VII 

ABDOMINAL  HERNIA 

Hernia  has  held  the  front  rank  in  nietUcal  hterature  from  the  earhest 
writings  until  to-cla}'.  .Vniong  surgeons  of  the  last  generation  ab- 
dominal herniie  were  held  to  be  the  single  exception  to  the  general 
inile  that  the  belly  must  not  be  opened  for  disease,  so  they  magnified  its 
importance.  The  literature  of  hernia  is  enormous — out  of  all  propor- 
tion to  modern  conception  of  the  significance  of  the  le.sion;  but  even 
to-day  the  text-books  give  it  unlimited  space.  I'homas  Br}-ant, 
publishing  twenty  years  ago,  devoted  to  hernia  one-twentieth  of  his 
great  volume;  so  did  Druitt  in  1859,  and  CheHus  in  1847.  Recent 
writers  are  more  reasonable,  but  the  subject  is  a  favorite  still,  and  it 
seems  that  custom  cannot  stale  its  infinite  variety. 

Hernia  is,  properly,  the  protrusion  of  a  viscus  or  j^art  of  a  viscus 
from  the  cavity  normally  containing  it.  The  term,  unqualified,  applies 
to  the  viscera  of  the  abdomen.  A  hernia  is  named  from  the  region 
in  which  it  appears — abdominal,  inguinal,  scrotal;  or  from  the  opening 
through  which  it  passes — obturator;  or  from  the  organ  jjrotruded — 
enterocele,  epiplocele,  cystocele. 

Inguinal  hernia,  the  commonest  form  of  hernia,  is  not  easily  to  be 
understood  by  the  beginner,  just  as  formerly  it  was  not  easily  to  be 
cured.  That  may  be  a  reason  for  our  constant  interest  in  the  whole 
subject  of  hernia;  yet,  except  for  certain  minor  points  of  detail,  the 
anatomy  of  most  hernise  is  not  difficult  of  comprehension.  Let  me 
illustrate  by  a  simple  example  what  commonly  takes  place  when  a  man 
is  ruptured.  Suppose  I  cover  the  outside  of  a  snowbank  with  a  sheet, 
then  wrap  my  hand  in  a  towel  and  thrust  my  fist  through  the  snow 
from  the  inner  side  of  the  bank.  Xo  matter  how  far  I  push  my  hand, 
it  will  always  carry  before  it  the  confining  towel  and  the  sheet  on  the 
outer  side  of  the  bank.  In  like  manner  a  coil  of  intestine  thrust  through 
the  abdominal  wall  will  always  cany  before  it  the  confining  (parietal) 
peritoneum,  and  the  skin  and  superficial  fascia  on  the  outer  side  of  the 
abdomen.  The  hernia  cleaves  its  way  between  muscles  and  aponeu- 
roses, and  it  is  wont  to  choose  for  its  point  of  attack  the  weakest  places 
in  the  abdominal  wall.  Generally,  it  seeks  places  low  in  the  abdomen — 
the  inguinal  canal,  where  the  spermatic  cord  or  round  ligament  passes 
out;  the  femoral  ring,  where  the  femoral  vessels  pass  under  Poupart's 
ligament;  the  umbilicus,  and  such  other  points  of  least  resistance. 
Besides  the  common  hernial  regions  just  mentioned,  we  have  to  deal 
with  ventral,  epigastric,  diaphragmatic,  gluteal,  sciatic,  and  lumbar 
hemise;    while  there  are  certain  rare  and  interesting  forms  of  internal 

192 


ABDOMINAL    HERNIA 


193 


hcrniae — retroperitoneal  hernise,  which  do  not  reach  the  surface  of  the 
body.  Such  are  the  anatomic  terms  describing  the  site  of  a  hernia. 
There  are  also  certain  cHnical  terms  which  describe  the  condition  of  a 
hernia — reducible,  irreducible,  incarcerated,  inflamed,  strayigidated. 

Etiology. — A  hernia  may  be  either  congenital  or  acquired.  The 
congenital  form  is  common,  though  it  is  often  transient.  ^lalgaigne 
stated  that  about  5  per  cent,  of  all  infants  have  congenital  hernia — 
inguinal,  femoral,  or  umbilical — and  his  estimate  is  probabl}'  correct. 
Congenital  hernise  are  due  to  an  imperfect  closure  of  canals  or  ducts 
which  are  patent  in  the  fetus.  Commonl}-,  these  congenital  hernise  do 
not  persist  beyond  infancy,  and  it  is  interesting  to  note  that  of  adults 


Fig.  104. — Anterior  abdominal  wall,  viewed  from  behind,  showing  the  peritoneal 
fossae:  A,  Obliterated  urachus:  B,  fold  of  deep  epigastric  artery-;  C,  obliterated 
hypogastric  arteries:  D,  fossa  at  the  internal  abdominal  ring;  E,  fossa  behind  the 
external  abdominal  ring  i  Campbell,  adapted  from  Sobotta). 

suffering  from  hernia,  but  5  or  6  per  cent,  will  be  found  to  have  con- 
genital  hernise.  "This  protrusion  may  occur  after  the  person  has 
reached  adult  life,  even  though  the  defect  has  existed  during  all  the 
preceding  years,  but  by  far  the  greater  number  of  congenital  hernise 
do  occur  in  infancy  or  early  childhood.  When  we  speak  of  congeni- 
tal hernia,  therefore,  it  does  not  indicate  at  what  age  such  hernia  may 
have  developed,  but  does  clearly  mean  that  the  hernia  has  come  down 
into  a  sac  already  formed.''^  Congenital  hernia  seems  to  be  hereditary 
in  many  families,  and  to  be  found  especially  among  the  offspring  of  fee- 
ble and  ill-nourished  persons,  as  well  as  among  rachitic,  syphilitic,  and 
1  W.  B.  De  Garmo,  Abdominal  Hernia,  p.  56. 
13 


194  THK    ABDOMKX 

undcvelopctl  children.  It  is  more  common  among  the  children  of  the 
poor  than  among  the  rich.  Ill-nourished  children  with  enfeebled 
digestive  organs,  with  bloated  abdomens,  subject  to  colics  and  diar- 
rheas, and  with  weak  abdominal  walls,  induce  and  encourage  hernia  by 
their  frequent  crying,  straining,  and  vomiting. 

Beside  the  ruptures  of  infancy,  hernia  is  a  common  affliction  of  adult 
life.  About  5  per  cent,  of  mankind  suffer  from  it.  The  conditions 
predisposing  to  hernia  are  numerous,  curiously  complicated,  and  still 
subject  to  dispute.  Some  persons  are  the  subjects  of  multiple  hernia?, 
behind  which  tendency  there  appears  to  be  a  condition  of  faulty  de- 
velopment. This  fault}'  development  is  especially  common  in  the 
umbilical  region.  Russell  ^  states  that  femoral  hernia  results  from  the 
existence  of  a  sac  arising  in  an  early  stage  of  development  when  the 
limb  buds  are  being  formed,  and  that  at  this  stage  a  diverticulum  of 
the  pleuroperitoneal  cavity  is  drawn  down  into  the  limb.  He  believes 
also  that  inguinal  hernia  is  due  to  a  similar  sacculation  of  the  peritoneal 
pouch.  The  intestinal  and  properitoneal  herniae  result  from  portions 
of  the  peritoneum  being  caught  in  the  abdominal  wall  during  its  de- 
velopment. 

As  a  fact,  degrees  of  obliteration  of  the  vaginal  process  or  peritoneal 
protrusion  vary.  In  the  case  of  inguinal  hernia  after  infancy,  it  is 
uncommon  to  find  a  communication  between  the  vaginal  process  in  the 
peritoneum  and  the  scrotal  end,  though  the  process  may  remain  patent 
in  the  region  of  the  cord  as  far  as  the  internal  ring. 

However  all  this  ma}^  be,  it  is  certain  that  there  are  weak  places  in 
some  individuals — large  abdominal  rings  and  lax  muscles  and  aponeu- 
roses. In  such  individuals  herniae  develop  insidiously;  the  vaginal 
process  may  advance  and  distend  gradually  without  containing  viscera, 
so  that  it  is  only  after  the  apparently  accidental  invasion  of  the  viscera 
that  the  hernia  becomes  evident  to  the  patient.  There  is  an  entirely 
different  class  of  persons  who  develop  hernia  suddenly  and  painfully. 
These  are  active,  vigorous  men,  athletes  and  laborers  who,  by  some 
sudden  and  severe  exertion,  force  down  a  hernia  through  a  previously 
normal  ring.  The  hernia  may  then  become  caught  in  the  tightening 
ring,  and  the  whole  process  may  be  associated  with  severe  pain  and 
distress.  The  immediate  causes  of  hernia,  in  all  classes  of  individuals, 
may  be  heavy  lifting,  stretching,  straining,  coughing,  sneezing,  and 
similar  vigorous  muscular  acts.  Excessive  length  of  the  mesentery, 
sometimes  exists,  and  it  may  be  that  the  pressure  of  a  dependent  and 
full  loop  of  intestine  weakens  the  lower  part  of  the  abdominal  waU. 
In  some  cases  a  mass  of  fat  forms  and  advances  before  the  hernia, 
bearing  to  it  a  causative  relation,  and  then,  as  Da  Costa  says,  cjuoting 
Lucas-Championniere :  "  When  a  person  begins  to  take  on  fat,  it  is  de- 
posited not  only  under  the  skin,  but  also  in  the  omentum,  mesentery, 
and  subperitoneal  tissues.  This  semifluid  fat  is  easily  influenced  by 
pressure.  The  deposit  of  fat  within  the  abdomen  lessens  the  size  of 
that  cavity,  intra-abdominal  pressure  is  increased,  and  fat  protrudes 
1  R.  Hamilton  Russell,  Lancet,  March  12,  1904. 


AHDO.MIXAL    HERNIA  195. 

at  any  weak  spot  in  the  wall.  Th(>  protruding  mass  of  fat  adheres  to 
and  makes  traction  uj)on  the  peritoneum,  and  this  membrane  is  drawn 
upon  to  form  a  sac,  and  the  sac  is  surrounded  by  fat.  This  method  of 
formation  is  frequently  noticed  in  umbilical  herniae." 

The  pregnant  state  is  a  frequent  cause  of  hernia  in  women,  but  males 
are  three  times  as  liable  to  rupture  as  are  females. 

Such  being  the  causes  of  hernia,  in  general  terms,  it  is  interesting  to 
study  further  certain  characteristics  common  to  all  ruptures.  I  have 
spoken  of  herniae  as  reducible,  irreducible,  incarcerated,  inflamed,  and 
strangulated.  All  herniae  have  certain  anatomic  points  in  common  also 
— coverings,  a  sac,  and  contents  of  the  sac. 

Reducible  hernia,  as  is  obvious  from  its  name,  is  a  hernia  the  con- 
tents of  which  may  be  caused  to  return  into  the  abdominal  cavity. 
This  state  of  hernia  is  the  commonest  of  all.  Most  of  the  patients  who 
consult  you  for  rupture  have  these  herniae  which  come  and  go.  If  the 
patient  stands  up  and  strains,  a  swelling  will  apear.  If  he  lies  down 
and  relaxes,  the  swelling  will  disappear,  or  may  be  easUy  pushed  back 
into  the  abdominal  cavity  by  taxis,  as  the  manipulation  is  called. 

A  word  in  regard  to  taxis:  The  student  or  inexpert  practitioner 
should  see  taxis  performed  by  an  experienced  hand  if  he  is  to  realize 
what  proper  taxis  means.  Ordinarily,  taxis  is  extremely  simple — 
a  small  hernia  can  be  put  back  readily  by  the  patient  himself;  but  it 
is  in  the  cases  of  large,  incarcerated  herniae  that  the  expert  finds  his 
field.  Lift  the  hernia  mass  directh'  upward,  so  that  the  contents  of 
the  sac  tend  to  fall  straight  down  into  the  ring.  Then  make  the 
approach  of  the  hernial  contents  toward  the  ring  through  a  funnel- 
shaped  canal  formed  by  the  manipulator's  fingers.  Usually  the  fingers 
of  one  hand  form  such  a  funnel,  while  the  fingers  of  the  other  hand 
knead  and  mold  the  contents  of  the  sac.  Sometimes  a  modified  Trendel- 
enburg position  helps ;  sometimes  a  hypodermic  of  morphin,  or  the  long 
immersion  of  the  patient  in  a  hot  bath  before  and  during  the  manipula- 
tions. Femoral  hernia  in  its  early  stages,  and  before  the  ring  has 
become  widely  distended,  offers  the  peculiarity  of  a  curiously  intricate 
canal,  formed  somewhat  like  the  curl  of  the  letter  /.  To  reduce  a  small 
femoral  hernia,  therefore,  the  surgeon  molds  the  contents  of  the  sac 
do"^TLward,  then  backward,  then  upward. 

Often,  by  palpating  or  percussing  the  hernia,  one  may  discover  the 
character  of  the  sac's  contents,  and  will  conclude  that  there  is  present 
a  mass  of  omentum  or  a  knuckle  of  intestine.  Sometimes,  when  the 
patient  consults  you,  you  will  see  no  hernia,  even  when  he  stands  up 
and  strains,  but  you  will  be  able  to  detect  its  presence,  or  potential 
presence,  by  inserting  a  finger  into  the  suspected  ring  and  directing 
him  to  cough  or  strain,  when  a  distinct  impulse  will  be  felt,  as  of  a  water- 
bag  impinging  on  the  finger.  These  patients  with  reducible  hernia 
rarely  have  troublesome  symptoms,  the  most  that  they  complain  of 
being  distress  at  the  hernial  opening,  and  more  or  less  general  bellyache 
when  the  viscera  protrude.  Sometimes  there  are  dyspepsia,  constipa- 
tion, and  nausea. 


19(J  THK    ABDOMEN 

Irreducible  hernia  is  anotlicr  term  which  is  sclf-explanatoiv.  A 
patient  comes  to  you  with  a  ruptui'e  which  cannot  be  i-eturnecl  into 
the  abdomen,  of  which  rupture  he  gives  a  history  that  it  has  l)een 
out  a  long  time.  It  may  be  of  any  size — which  is  true  also  of  reducible 
hernia — from  that  of  a  pullet's  egg  to  an  enormous  sac  containing  most 
of  the  intestines  and  omentum.  Thei'e  are  various  causes  for  its  being 
irreducible,  the  commonest  being  adhesions  between  the  coverings  of 
the  sac  and  the  sac  with  its  contents — adhesions  due  to  a  low  grade  of 
peritonitis.  Another  cause  is  incarceration.  An  incarcerated  hernia 
(or  obstructed  hernia)  is  one  in  which  the  fecal  stream  is  dammed  up 
and  arrested  when  the  hernia  is  down,  so  that  the  distended  bowel 
cannot  be  returned  through  the  ring,  but  the  contents  of  the  sac  suffer 
no  immediate  anatomic  change,  because  their  circulation  remains 
intact.  In  other  words,  an  incarcerated  hernia  is  not  an  immediate 
source  of  danger.  It  is  a  common  outcome  of  irreducible  hernia,  and 
demands  attention.  It  enlarges  and  becomes  tender,  painful,  and 
dull  on  percussion;  pressure  reduces  its  size,  but  it  cannot  be  com- 
pletely reduced,  and  it  still  shows  an  impulse  on  coughing.  There  is 
apt  to  be  associated  nausea,  and  there  is  variable  constipation,  with 
occasional  vomiting.  An  irreducible  hernia  may  become  inflamed,  a 
condition  to  which  I  have  already  alluded.  The  mass  becomes  hot 
and  tender,  hard  and  distended.  It  cannot  be  reduced,  and  gives  rise 
to  the  same  symptoms  as  those  of  incarcerated  hernia,  with  fever  in 
addition;  but  there  is  still  an  "impulse  on  coughing."  and  the  constipa- 
tion is  not  absolute.  With  proper  treatment  the  inflammation  will 
subside  usually,  but  it  leaves  behind  it  adhesions,  and  establishes  a 
condition  tending  to  subsequent  incarceration  and  to  possible  future 
strangulation. 

Strangulated  hernia  is  the  most  serious  form  of  irreducible  hernia 
with  which  we  ha\-e  to  deal,  and  it  is  about  the  subject  of  strangulated 
"hernia  that  the  greatest  interest  in  hernia  centers.  Physician  and 
patient  alike  must  be  taught  to  look  toward  strangulation  as  the  pos- 
sible outcome  of  every  hernia.  The  condition  is  a  frightful  calamity, 
and  the  danger  to  life  is  imminent.  The  three  great  surgical  emer- 
gencies of  the  old  writers  were  hemorrhage,  suffocation,  antl  strangu- 
lated hernia,  and  of  the  three,  strangulated  hernia  is  still  the  most 
common  and  the  most  difficult  of  control. 

In  Chapter  II  we  studied  intestinal  obstruction  and  intestinal 
strangulation,  and  saw  that  strangulation  may  be  the  last  and  serious 
stage  of  obstruction.  So  in  the  case  of  hemia — an  incarcerated  hernia 
contains  usually  obstructed  bowel — an  obstruction  to  the  fecal  stream. 
A  strangulated  hernia — a  hemia  from  which  the  nutrition,  the  blood- 
supply,  has  been  eliminated — may  be  the  end-result  of  incarceration. 
Omentum  as  well  as  bowel  may  become  strangulated.  Observe  further 
that  strangulation  may  take  place  in  an  old  irreducible  hernia,  and 
that  it  may  take  place  suddenly  also  in  a  hemia  hitherto  reducible, 
or  it  may  be  the  initial  evidence  of  a  fresh  hernia.  One  must  always 
distinguish  the  elastic  constriction  or  strangulation  from  fecal  impac- 


ABDOMINAL   HERNIA  197 

tion  or  incarceration.  Sti'anfiulatcd  hernia  occurs  thus:  a  loop  of 
intestine  becomes  crowded  tlown  into  the  sac,  and  when  the  increased 
amount  of  pressure  diminishes,  the  hernial  ring,  which  has  been  forcibly 
distended,  contracts  and  grasps  the  loop  with  an  elastic  grip.  Thus 
stoppage  of  the  bowels  is  established,  as  w^ell  as  interference  with  the 
gut's  circulation.  The  circulatory  disturbance  may  be  venous  only, 
or  both  veins  and  arteries  may  be  shut  off,  and,  according  to  the  degree 
of  strangulation,  the  further  destructive  processes  are  slow  or  rapid. 
If  the  arteries  are  still  patent,  the  irreducible  viscera  become  engorged, 
exudation  follows,  and  strangulation  gradually  becomes  complete. 
The  bow^el  then  becomes  necrotic,  often  with  astonishing  rapidity,  so 
that  sometimes  it  is  no  longer  viable  after  eighteen  or  twelve  hours 
even.  The  terminal  intestinal  arteries  do  not  anastomose.  The 
lumen  of  the  gut  is  loaded  with  active  bacteria,  under  the  most  favora- 
ble conditions  for  making  trouble.  Much  the  same  condition  results 
when  both  veins  and  arteries  are  suddenly  occluded.  In  either  case 
there  follow  necrosis,  ulceration,  gangrene,  peritonitis.  Even  if  the 
gut  be  found  viable  at  operation  and  be  returned  to  the  abdominal 
cavity,  damage  to  its  walls  may  have  occurred  in  one  or  more  places, 
so  that  later,  with  healing  ancl  scar-formation  in  the  intestine,  there 
may  result  stenosis  and  obstruction.^  As  a  rule,  however,  if  the  strangu- 
lation is  reheved  early,  the  intestine  will  recover.  If  necrosis  supervene 
and  surgical  relief  is  not  provided,  the  patient  will  die  of  shock  or 
general  peritonitis.  In  rare  cases — about  5  per  cent. — the  destructive 
process  will  penetrate  the  sac  and  skin,  and  the  patient  will  recover  with 
a  fecal  fistula  or  artificial  anus. 

The  symptoms  and  signs  of  strangulated  hernia  are  in  large  measure 
the  classic  ones  seen  in  other  intestinal  strangulations.  One  finds 
that  the  hernia,  perhaps  formerly  reducible,  cannot  now  be  replaced.^ 
If  not  recently  formed,  it  is  larger  than  usual,  tense,  firm,  or  even  hard; 
without  resonance,  without  expansile  impulse  (a  hernia  incarcerated 
merely  expands  with  straining;  and  in  this  fact  Hes  an  important 
distinction  between  strangulation  and  incarceration) .  The  strangulated 
hernia  is  painful  and  tender  on  pressure,  especially  at  its  neck.  The 
bowels  do  not  act,  though  they  may  often  be  felt  contracting,  and 
may  cause  colic  and  spasmodic  pains,  especially  at  the  navel  and  the 
pit  of  the  stomach.  With  this  pain  there  are  commonly  some  tender- 
ness and  a  feeling  of  tightness  in  the  abdomen,  particularly  in  the 
umbilical  region,  and  between  it  and  the  hernia.  The  patient  is  often 
nauseated,  and  vomits  nearly  all  the  food  and  drink  that  he  swallows, 
besides  gastric  secretions,  bile,  or  the  diluted  contents  of  the  small 
intestine.  The  pulse  and  respiration  are  usually  quickened  and  rather 
feeble;  the  patient  feels  and  looks  wretched  and  miserable— ''anxious," 
as  we  say.  He  cannot  sleep  or  eat,  and  the  hands  and  feet  are  apt  to 
become  cold,  shrunken,  and  dusky. 

1  See  important  article  by  Percy  W.  G.  Sargent,  Ann.  Surg.,  May,  1904.  _ 

2  There  is  a  grapliic  description  of  tliis  condition  in  Sir  James  Paget  s  Clinical 
Lectures  and  Essays,  1875. 


198  THE   ABDOMEN 

Whenever  all  these  things  are  observed,  and  when  they  remain  after 
reasonable  attenij^ts  at  the  hernia's  reduction  without  ojiei-ation,  }'ou 
may  hold  that  the  operation  shoukl  be  done  without  delay.  Much 
more,  if  possible,  should  it  be  clone  if  all  these  phenomena  be  worse  than 
I  have  described.  When  the  integuments  over  the  hernia  are  inflamed, 
thick,  sodden,  ruddy,  or  emph}'sematous;  when  the  whole  abdomen  is 
swollen,  tense,  and  tender;  when  the  vomitus  is  like  the  liquid  feces 
of  the  ileum;  the  pulse  rapid,  feeble,  and  small;  the  skin  cold,  dusky, 
and  clammy;  when  the  patient  is  dim  in  sense  and  mind  or  in  an 
anguish  of  misery,  with  retching  and  hiccough — when  all  or  the  greater 
part  of  these  elements  of  what  the  old  writers  call  a  miserere  are  com- 
bined, then,  without  trying  any  other  method  of  reduction,  you  must 
operate  instantly,  though  you  may  have  only  the  slenderest  hope  of 
doing  good,  and  a  serious  fear  of  seeming  to  do  harm. 

The  foregoing  fine  account  of  strangulated  hernia  is  taken  almost 
verbatim  from  Paget's  delightful  book.  His  description  will  alwaj^s 
apply,  and  there  is  little  the  modern  surgeon  can  add  for  aid  in  the 
diagnosis.  We  note  the  temperature,  which  is  frequently  subnormal 
at  first,  rising  as  the  primary  shock  passes  and  peritonitis  develops. 
It  may  reach  102°  or  103°  F.  The  pulse,  at  first  rapid,  feeble,  thready, 
becomes  somewhat  hard  and  wiry  with  the  advent  of  sepsis;  later  it  falls 
away  to  a  flickering  stream.  There  is  almost  alwa3's  a  slight  leuko- 
cytosis— 12,000  to  20,000.  The  urine  becomes  concentrated;  the 
tongue  is  dry  and  furred,  with  red  cracks  across  it;  the  breath  is  horribly 
offensive.     Such  is  the  scene. 

We  found  our  diagnosis  on  finding  a  hernia  which  is  irreducible, 
non-expansile  "on  cough,"  and  tender;  on  a  feeble,  rapid  pulse;  an 
anxious  expression;  a  slightly  chstended  abdomen,  tender  at  the  navel, 
epigastrium,  and  vicinity  of  the  rupture;   on  nausea  and  vomiting. 

Treatment. — Fortunately,  the  precision  of  our  diagnosis  does  not 
involve  so  immediately  the  question  of  operating  or  not  operating  as 
was  the  case  in  former  times.  To-day  one  operates  in  all  cases  of  trou- 
blesome hernia.  One  operates  if  in  doubt,  and  solves  his  doubts  by 
operating. 

So  different  is  the  question  of  the  treatment  of  strangulated  hernia 
from  the  question  of  the  treatment  of  the  other  types  of  hernia  that  I 
will  anticipate  by  discussing  briefly  here  the  treatment  of  strangulated 
hernia.  In  many  respects  the  problem  of  hernia  is  like  the  problem  of 
appendicitis.  Like  appendicitis,  hernia  may  be  chronic  or  acute.  It 
may  come  and  go.  One  may  procrastinate  for  long  in  the  treatment, 
using  palliative  measures.  Either  appendicitis  or  hernia  may  wake  up 
at  any  moment,  to  become  alarming  and  deadly.  Both  kill  through 
perforation,  peritonitis,  sepsis.  In  both,  when  quiescent,  the  radical 
operation  is  easy,  rapid,  safe,  and  sure.  In  both,  when  acute,  the 
operation  is  inevitable,  but  not  always  life-saving.  The  term  "radical 
cure  of  hernia"  applies  commonly  to  the  treatment-at-leisure  of  chronic 
hernia,  not  strangulated.  Now,  when  we  have  to  deal  with  strangulated 
hernia,  our  endeavor  nmst  be  to  avert  impending  death  by  relieving 


INGUINAL  HERNIA  199 

the  stranp;ulation.  After  that,  if  the  patient's  strength  permit,  one 
may  perform  a  radical  cure  b}'  sewing  up  the  ring.  Our  previous  dis- 
cussion of  intestinal  strangulation  and  its  treatment  (Chapter  II)  applies 
to  the  matter  now  in  hand.  In  a  word,  one  cuts  down  upon  the  sac  of 
strangulated  hernia,  opens  it  (herniotomy),  and  enlarges  the  ring  so  as  to 
permit  the  viscera  to  slip  back  into  the  abdomen.  Then,  before  replacing 
the  viscera,  the  surgeon  must  make  sure  that  they  are  viable.  Obvious 
necrosis  must  be  removed,  even  to  the  resection  of  intestine  and  excision 
of  omentum;  and  such  further  steps — anastomosis,  end-to-end  suture 
(or  Murphy  button),  or  artificial  anus — must  be  employed  as  the 
exigencies  of  the  case  and  the  condition  of  the  patient  will  allow.  The 
question  of  the  viability  of  bowel  is  often  difficult.  Glossy,  firm,  purple 
bowel  is  viable.  Dull,  friable,  black,  stinking  bowel  is  gangrenous. 
But  there  are  man}-  intervenmg  stages.  In  general  terms,  doubtful 
looking  gut  that  gradually  improves  in  color  on  being  released  and 
wrapped  in  warm  cloths  may  be  returned.  Bowel  persistently  dull  and 
discolored  should  be  excised,  or  at  least  incised  for  fecal  drainage,  and 
fastened  into  the  wound  for  observation  and  further  trentment.  After 
the  operation  these  cases  demand  anxious  care.  The  questions  of 
feeding  and  moving  the  bowels  depend  for  their  answer  upon  whether 
or  not  the  mtestine  has  been  injured.  In  general  terms  a  vigorous 
patient,  with  viscera  not  wounded,  may  be  pushed  on  rapidly,  as  after 
any  exploratory  abdominal  section.  But  the  presence  of  intestine 
wounded  by  resection  necessitates  rectal  feeding,  prolonged  care,  and 
such  a  slow  convalescence  as  we  have  seen  in  the  case  of  all  operations 
on  the  intestines. 

Let  us  now  take  up  in  more  detail  the  anatomy  of  some  of  the  com- 
moner forms  of  hernia,  with  diagnosis  and  treatment. 

INGUINAL  HERNIA 

Inguinal  ^  hernia  is  the  most  frequent  rupture  in  males.  It  occurs 
occasionally  in  females.  There  are  two  forms  of  ingaiinal  hernia — 
the  direct  and  the  indirect.  We  must  glance  for  a  moment  at  their 
anatomy .2  The  inguinal  region,  for  surgical  purposes,  is  that  portion 
of  the  abdomen  bounded  by  Poupart's  ligament,  the  external  border 
of  the  rectus  muscle,  and  a  horizontal  line  drawn  from  the  anterior 
superior  spine  of  the  ilium  to  the  rectus.  The  parietal  layers  here  are : 
(1)  Skin  and  superficial  fascia;  (2)  aponeurosis  of  the  external  oblique; 
(3)  the  internal  oblique  and  transversalis  muscles,  which  are  not  at- 
tached to  the  injier  half  of  Poupart's  ligament;  (4)  the  transversalis 
fascia;  (5)  the  subserous  connective  tissue,  in  which  lie  the  deep  epi- 
gastric artery  and  vein;  and  (6)  the  parietal  peritoneum.  Layers  two, 
three,  and  four  are  penetrated  by  the  spermatic  cord  in  an  obfique 
direction.  The  cord  lies  in  the  inguinal  canal,  which  is  a  potential 
passage  only,  not  open  except  when  distended  by  a  hernia.     The  stu- 

*  Lat.,  ingiien,  the  groin. 

2  The  teacher  or  student  may  use  profitably  D.  X.  Eisendrath's^models,  illustrated 
in  his  paper  published  in  Jour.  Amer.  Med.  Assoc,  March  IS,  1905. 


200 


THK    AI5D(XME.\ 


(lent  iim.^t  got  clearly  in  hiw  mind  the  position  of  the  coid  and  its  relations 
— that  is  a  leading  feature  of  our  problem.  The  cord  is  always  outside 
of  the  peritoneum.  To  trace  it  Inickward:  it  starts  from  the  base  of  the 
bladder  and,  passing  upward  and  outward,  outside  of  the  peritoneum, 
between  it  and  the  transversalis  fascia,  it  turns  sharply  downward  and 
forward  into  the  internal  ring,  beneath  the  transversalis  fascia  and 
internal  obli(iue  fascia,  which  two  fascia)  are  here  linked  together  to 
form  the  conjoined  tendon.  Passing  through  the  internal  ring  and 
the  inguinal  canal,  which  is  from  1^  to  2  inches  long,  the  cord  emerges 
from  the  canal  through  a  slit  in  the  external  oblicjue  aponeurosis — a 
slit  known  as  the  external  ring.  The  cord  is  now  beneath  the  super- 
ficial fascia,  and  drops  over  the  spine  of  the  pubes  into  the  scrotum. 
At  the  point  where  the  cord  passes   the  transversalis  fascia  the  latter 


i— i-^ 


> 

.  3 


Fig.  105. — Dissection  of  in^juinal  canal:  1,  External  oblicjue,  turned  down;  2, 
internal  obliqne;  3,  transversalis;  4,  conjoined  tendon;  5,  rectus  abdominis  with  its 
sheath  opened;  6,  triangular  fascia;  7,  cremaster  (Heath). 

structure  .sends  out  a  prolongation  called  the  infundibuliform  fascia, 
which  accompanies  the  cord  into  the  scrotum  and  forms  the  tunica 
vaginalis  communis.  There  are  two  other  fascia?  accomjjanying  the 
cord — structures  of  both  anatomic  and  of  practical  surgical  interest — 
the  cremasteric  fascia  from  the  internal  oblique,  and  the  intercoluranar 
fascia  from  the  external  oblique.  So  w^e  see  that  the  cord,  as  it  passes 
through  the  inguinal  canal,  is  surrounded  by  sundry  structures  of 
varying  strength.  In  front  of  it  is  the  external  oblique  aponeurosis 
(and  some  fibers  of  the  internal  oblique  in  its  outer  part) ;  behind  it  is 
the  conjoined  tendon  of  the  internal  oblique  and  transversalis  and  the 
transversalis  fascia;  within  (upper  wall)  are  the  arching  fibers  of  the 
conjoined  tendon,  beyond  which  lies  the  rectus  muscle  with  its  cover- 
ings;   without   (lower  wall)  is  the  stout  Poupart's  ligament.     An  im- 


INGUINAL   HKKNIA 


201 


portant  landmark  is  the  deep  epigastric  artery,  which  springs  from  the 
external  iliac,  where  it  passes  under  Poupart's  ligament,  and  mns  up- 
ward and  inward  along  the  outer  edge  of  the  rectus  muscle.  The  outer 
edge  of  the  rectus,  Poupart's  ligament,  and  the  deep  epigastric  artery 
form  Hesselbach's  triangle.  The  artery  hes  in  the  subserous  connec- 
tive tissue  outside  of  the  peritoneum.  The  relation  of  this  artery  to 
the  two  rings  determines  direct  and  indirect  hernia.  The  artery  passes 
upward  behind  and  between  the  rings.  Immediately  to  its  outer  side 
is  the  internal  ring,  the  entrance  to  the  canal  (we  are  looking  at  these 
structures  from  within  the  abdomen) .  Immediately  to^  its  inner  side 
lies  the  depression  or  fossa  representing  the  external  ring.     The  epi- 


Fig.  106. — Aponeurosis  of  external  oblique  muscle,  in  which  is  shown  the  external 
ring  covered  by  inter  columnar  fascia  (de  Garmo). 

gastric  vessels,  therefore,  form  a  strong  ridge,  on  either  side  of  which 
lies  a  weak  depression.  Through  these  weak  depressions  hernite  pro- 
trude—direct hernia  plunging  through  the  wall,  to  the  inner  side  of 
the  artery,  and  emerging  at  the  external  ring;  indirect  hernia,  forcing 
its  way  dowm  through  the  internal  ring  and  canal,  in  front  of  and  across 
the  aiiery,  to  emerge  also  at  the  external  ring.  So  where  they  emerge 
the  direct  hernia  carries  before  it  the  peritoneum,  fascia  transversahs, 
conjoined  tendon,  and  intercolumnar  fascia,  much  thinned,  to  be  sure; 
while  the  oblique  or  indirect  hernia,  as  it  worms  its  way  through  the 
canal,  carries  before  it  none  of  these  structures  except  the  peritoneum. 
The  nerve-supply  of  these  parts  is  interesting,  and  it  is  wise  to  spare 
nerve-branches   in  operating  upon  hernia.     The  terminal  branches  of 


202 


THE    ABDOMEN 


the  ilio-inguinal  nerve  emerge  at  the  external  abdominal  ring,  and  the 
hypogastric  branch  of  the  iliohypogastric  perforates  the  aponeurosis 
of  the  external  obliciue  above  and  to  the  outer  side  of  the  external  ring. 

There  are  three  arteries — two  of  them  important:  the  spermatic 
artery,  which  supplies  the  testicle;  the  artery  of  the  vas  deferens, 
lying  in  the  sheath  of  the  vas;  and  the  cremasteric  branch  from 
the  epigastric.  The  veins  forming  the  pampiniform  plexus  make  up 
the  bulk  of  the  cord.  If  you  understand  the  anatomy  of  this  region, 
the  various  operations  appear  simple  enough. 

The  diagnosis  of  inguinal  hernia  is  usually  easy,  though  occa- 
sionally it  may  offer  diffictdtics.  I  have  said  that  the  sw^elling  may 
disappear  when  the  patient  lies  down.     This  fact  of  the  disappearance 


Fig.  107. — Aponeurosis  opened  to  internal  ring,  showing  lower  laorder  of  internal 
oblique  muscle;   transversalis  fascia  in  deep  wall  of  canal  (de  Garmo). 

of  the  swelling  confirms  the  diagnosis  of  hernia.  For  further  confirma- 
tion the  surgeon  may  introduce  his  finger  into  the  ring  to  ascertain 
the  presence  of  "  impulse  on  cough."  It  is  not  always  possible  to  dis- 
tinguish direct  from  indirect  hernia,  but  the  practitioner  should  re- 
member that  direct  hernia  rareh'  becomes  large  enough  to  descend 
into  the  scrotum;  while,  on  the  contrary,  indirect  hernia  may  descend 
and  cause  an  enormous  scrotal  swelling.  We  differentiate  hernia  from 
inguinal  adenitis,  which  presents  a  hard,  unvarying  swelling;  from 
inguinal  sarcoma,  which  is  hard  and  unvarying  also;  from  psoas  abscess, 
which  fluctuates  and  may  be  confused  with  inguinal  hernia;  from 
various  hard  and  soft  tumors  of  the  testicle  and  cord,  which  tumors 
are  constant;   and  from  hydrocele,  which  most  closely  resembles  hernia. 


INGUINAL   HERNIA 


203 


Hydrocele  is  fluctuant,  dull  on  percussion,  shows  transmitted  light 
when  examined  by  the  hydroscope,  and  is  invariable  in  size,  except, 
of  course,  in  cases  of  congenital  hydrocele,  but  congenital  hydrocele 
is  commonly  associated  with  and  a  part  of  congenital  hernia. 

The  operative  treatment  of  both  forms  of  inguinal  hernia  has  now 
been  brought  to  such  perfection  that  palliative  measures  are  rarely 
considered  by  surgeons.  Yet  palliative  measures  have  their  value, 
and  by  palliation  I  mean  the  use  of  the  truss.  One  hesitates  to  advise 
a  radical  operation  upon  a  feeble  old  person,  and  one  shrinks  from 


Fig.  108.— Deep  dissection  of  inguinal  and  femoral  canals  (de  Garmo). 

operating  upon  persons  with  advanced  organic  disease — cardiac,  pul- 
monary, renal,  diabetic.  Moreover,  in  a  Hmited  class  of  cases  trusses 
will  cure  hernise— the  hernia?  of  children  under  four  years  of  age_  (the 
home-made  yarn-truss  will  often  suffice) ;  the  small  recent  hernise  of 
young  adults.  In  order  to  attain  this  result,  however,  you  must  enjom 
the  patient  to  wear  the  truss  constantly  that  the  hernia  may  not  come 
down,  else  a  single  violent  exertion  may  undo  the  good  work  of  months. 
The  only  hernise  suitable  for  truss  wearing  are  reducible  hernise.  Irre- 
ducible hernise  are  irritated  and  made  worse  by  a  truss.     Large,  irre- 


204 


THE   ABDOMEN 


ducible  scrotal  hernisc,  however,  may  be  supported  in  a  well-fitting  bag 
should  the  radical  ()i)eration  seem  inadvisable.  There  is  a  great  variety 
of  trusses  made  b}'  the  instrument-makers,  and  the  principle  of  them 


JO'.l. — Truss  in  place. 


all  is  a  stout  spring-belt  encircling  the  waist  and  furnished  with  a  pad 
to  overlie  the  hernial  ring.  These  pads  are  made  of  wood,  leather, 
cork,  and  similar  materials,  but  much  the  most  effective  and  comforta- 


Fig.  110. — Yarn-truss  for  congenital  hernia. 

ble  is  the  water-pad  truss,  devised  by  H.  H.  A.  Beach  some  twenty-five 
years  ago.  A  well-fitting,  easy,  water-pad  truss  will  hold  up  an  inguinal 
hernia  perfectly,  and  enable  the  patient  to  lead  a  comfortable  life  and 
indulge  in  almost  any  form  of  active  exercise. 


INGUINAL   HERNIA  205 

Fifteen  years  ago  we  told  patients  that  a  radical  cure  would  give 
about  an  even  chance  of  immunity  from  relapse.  To-day  we  are 
justified  in  saying  that  about  97  per  cent,  of  our  cases  can  be  cured 
permanently  by  operation.  The  development  of  the  operation  for 
inguinal  hernia  forms  an  interesting  historic  study,  but  in  this  place  I 
shall  limit  myself  to  describing  a  satisfactory  operation  for  each  form, — 
the  indirect  and  direct, — and  shall  refer  the  reader  to  the  literature 
of  the  subject  should  he  wish  to  study  a  variety  of  operations.  I  have 
before  me  a  list  of  28  men  who  have  devised  or  modified  operations  for 
inguinal  hernia,  and  with  a  few  exceptions  these  operations  are  quite 
similar.  All  of  them  depend  for  their  success  upon  a  perfect  aseptic 
technic,  for  it  is  since  the  days  of  aseptic  surgery  only  that  these  opera- 
tions have  proved  satisfactory. 


Fig.  111. — Irreducible  hernia  (de  Garmo). 

In  operating  for  inguinal  hernia  the  surgeon  endeavors  to  meet  and 
overcome  three  problems — the  dealing  with  the  sac,  the  dealing  with 
the  cord,  and  the  secure  closure  of  the  canal  or  ring.  Once  it  was 
thought  that  the  fossa  formed  within  the  peritoneal  cavity  by  the  closed 
sac,  after  operation,  gave  a  starting-point  for  recurrence,  and  doubtless 
this  is  true.  It  has  been  always  recognized  that  the  passage  of  the 
cord  through  the  abdominal  wall  inevitably  causes  a  weakening  of  the 
wall  at  that  point,  and  this  doubtless  is  true  also.  A  long  course  of 
experimenting  was  necessary  to  determine  just  what  structures  in  the 
abdominal  wall  should  be  sewed  together  in  order  to  provide  the 
strongest  barrier  against  the  recurrence  of  hernia.  We  have  solved 
this  problem  and  now  know  that  stout  aponeurotic  tissue  overlapped 
offers  a  firmer  barrier  than  does  muscle  tissue.  So  we  meet  the  three 
problems :  first,  by  tying  or  suturing  and  cutting  off  the  sac,  and  drop- 


206 


THE    ABDOMEN 


ping  the  stump  well  within  the  peritoneal  eavity  at  a  point  not  weakened 
by  the  past^age  of  the  cord,  if  possible.  We  transplant  the  cord,  or 
bring  it  out  through  a  new  opening  without  transplanting  it.  Bearing  in 
mind  that  the  prime  cause  of  weakness  in  the  inguinal  region  is  the  lack 
of  attachment  of  the  conjoined  tendon  to  Poupart's  licjanient  in  its  inner 
half,  we  make  good  the  defect  by  stitching  the  conjoined  tendon  to 
that  inner  half  of  Poupart's  ligament  and  to  Ciimbernat's  ligament — 
we  attempt  to  improve  on  nature. 

Method — Oblique  Inguinal  Hernia. — The  patient  is  put  to  bed  for 
a  couple  of  days  before  operation  and  the  bowels  thoroughly  evacuated 
by  castor  oil  and  enemata.  An  oblique  incision  is  made  5  or  6  inches 
long,  from  the  pubic  spine  upward  and  outward  over  the  course  of 
the  canal,  as  far  as  the  anterior-superior  spine  of  the  ilium,  parallel  to 
and  two  fingerbreadths  from  Poupart's  ligament.      The  external  ring 


Fig.  112. — Incision  for  cure  of  inguinal  hernia. 

quickly  is  developed  with  the  knife  and  with  gauze  dissection,  and  all 
bleeding  points  are  secured,  that  their  oozing  may  not  obscure  and 
soil  the  deeper  field  nor  favor  subsequent  infection.  For  a  space  of 
about  3  inches  around  the  incision  the  superficial  tissues  are  swept 
back  by  a  gauze  wipe,  so  as  thoroughly  to  expose  the  aponeurosis  .of 
the  external  oblique.  This  maneuver  greatly  facilitates  the  subsequent 
handling  of  that  aponeurosis.  The  inguinal  canal  is  then  slit  up  with 
scissors,  thus  dividing  thoroughly  the  external  oblique  and  exposing 
the  deeper  parts.  In  doing  this  avoid  the  two  nerves  of  the  region. 
(Some  surgeons  prefer  to  open  the  external  oblique  aponeurosis  half 
an  inch  above  and  to  the  inner  side  of  the  canal.)  The  edges  of  the 
opened  aponeurosis  are  now  seized,  firmly  retracted,  and  turned  back 
from  the  underlying  conjoined  tendon  with  further  gauze  dissection. 
You  will  see  that  the  deep  parts  are  now  thoroughly  exposed  down  to 
the  preperitoneal  fat.     The  hernia  bulges  into  the  wound,  its  sac  closely 


INGUINAL  HERNIA  207 

associated  with  the  coverings  of  the  spermatic  cord.  The  sui'geon 
must  next  separate  carefully  the  cord  from  the  sac.  One  cannot  always 
do  this  without  tearing  apart  the  structures  of  the  cord,  but  this  makes 
no  difTerence  so  long  as  the  vas,  the  arteries  (especially  the  artery  of  the 
vas),  and  two  or  three  good-sized  veins  are  left.  The  sac  is  most  easily 
separated  from  the  cord  by  firm  gauze  dissection,  and  sometimes  this 
maneuver  is  facilitated  by  opening  the  sac  and  holding  it  up  upon  the 
extended  fingers  inserted  within  it.  The  cremaster  may  be  well  de- 
veloped, in  which  case  one  may  utilize  it  in  closing  the  abdominal  wound. 
Split  it  off  and  separate  its  fibers  from  the  sac.  Now  tip  the  patient 
about  25  degrees  into  the  Trendelenburg  position,  elevate  the  sac,  and 


Fig.  113. — Oblique  incision  through  skin  and  superficial  fascia  down  to  fascia  of 
the  external  oblique  muscle.  Note  the  external  abdominal  ring,  made  apparent  by 
slight  bulging  caused  by  fuU  hernial  sac  (adapted  from  Scudder). 

return  its  contents  into  the  abdominal  cavity.  Secure  the  neck  of  the 
sac  with  a  stout  catgut  purse-string  suture ;  cut  off  the  stump  and  push 
it  back  within  the  internal  ring.  The  distal  end  of  the  sac  may  be 
dissected  out  or  left,  as  you  choose.  This  closure  of  the  peritoneal  sac 
must  be  made  secure.  If  the  peritoneum  is  thickened  or  is  overlaid 
with  fat,  I  recommend  sewing  up  its  opening  with  a  catgut  or  silk 
buttonhole  stitch  rather  than  tying  it  off  with  a  purse-string.  Be 
sure  also  that  the  sac  stump  is  free  from  all  adhesions,  both  inside  and 
out,  that  it  may  slip  well  back,  freely,  into  the  abdomen. 

Then  to  close  the  abdominal  wall— the  canal:  the  problem  is  un- 
like other  similar  problems  in  abdominal  surgery,  because  the  cord  is 


208 


THE   ABDOMEN 


in  the  way  of  a  tight  closure  of  the  wound.  There  are  two  methods 
of  treating  the  cord,  luring  it  out  a  httle  below  (1  or  2  inches)  the 
internal  ring,  stitch  together  the  conjoined  tendon  and  Poupart's  liga- 


Fig.  114. — Oblique  incision  in  line  of  fibers  of  the  external  oblique  fascia.  Ex- 
ternal oblique  fascia  freed  from  parts  beneath:  Note  fibers  above  of  internal  oblique 
conjoined  tendon,  below  well-developed  cremasteric  fibers,  bulging  sac  of  hernia, 
cord  showing  at  inner  angle  of  wound  (Scudder). 

ment,  and  let  the  cord  lie  upon  them  (transplanted)  with  the  aponeu- 
rosis of  the  external  oblique  stitched  over  it  to  cover  it  in  (Bassini). 
Or  else  carry  the  cord  to  the  very  bottom  of  the  abdominal  wound  and 


Fig.  llS.^The  sac  of  the  hernia  has  been  isolated  sufficiently  and  raised  by  for- 
ceps.     Note  scissors  opening  the  sac,  cord  in  lower  angle  of  wound  (Scudder). 

bring  it  out  alongside  of  the  pubic  spine;  with  the  cord  thus  out  of  the 
way  the  abdominal  wall  may  be  sewed  up  as  though  the  cord  did  not 


INGUINAL   HEKNIA 


209 


exist.     Whatever  the  treatment  of  the  cord  may  be,  you  must  see  to 
it  that  it  is  not  unduly  pinched  where  it  emerges  through  its  new  arti- 


Fig.  116. — The  suture  is  being  taken  through  and  across  the  neck  of  the  sac. 
Note  retractor  keeping  internal  ring  region  well  in  view.  Note  lifting  of  cord  by 
gauze-tape  (Scudder). 


Fig.  117. — Closure  of  canal  (Scudder). 

ficial  ring,  and  to  that  end  it  is  well  to  thin  it  do^^ai  somewhat  if  it  be 
large.  Thin  it  down  by  removing  a  few  veins  and  any  superabundant 
fat  tissue. 

14 


210 


THE   ABDOMEN 


In  sewin.ti'  u])  the  abdominal  wall — conjoined  tendon  to  Poupart's 
ligament — 1  prefer  to  use  a  mattress  suture  of  chromic  gut,  or  gut  pre- 
pared by  Bartlett's  method.  The  aponeurosis  of  the  external  oblicjue 
is  then  sewed  up  to  cover  in  the  deep  field.  I  emplo}-  a  button-hole 
stitch  of  catgut  for  the  external  oblique,  and  close  in  the  skin  wound 
with  a  running  hoi-se-hair  stitch.  Eveiy  student  will  recognize  the  fact 
that  details  of  this  method  may  be  varied  indefinitely.  Some  operators 
employ  silk  throughout;  some  kangaroo  tendon;  some  silver  or  copper 
wire;   the  main  principles  are  identical. 


Fig.    I  IN.  —  IlaLsted's  operation.     Mattrf.^s  suture  in  eli 


-f  eanal  (Kelly). 


In  some  large  hernise  of  long  standing  the  conjoined  tendon  ma}'  be 
so  thin  or  nearly  obliterated  that  it  cannot  be  employed.  In  such 
cases  Bloodgood  ^  recommends  making  use  of  the  edge  of  the  rectus 
instead  of  the  conjoined  tendon.  The  rectus  sheath  is  exposed  and 
divided  in  front  of  the  nmscle,  in  the  direction  of  the  muscle-fibers, 
upward  from  the  pubic  insertion.  The  muscle  bulges  from  the  cut  and 
is  caught  with  silk  sutures.  Deep  stitches  are  then  introduced,  joining 
the  rectus  to  Poupart's  ligament.  I  have  found  this  operation  satis- 
factory in  a  number  of  difficult  cases. 

Direct  Inguinal  Hernia. — As  Davis'  points  out,  direct  hemiae  are 

1  Joseph  C.  Bloodgood,  Johns  Hopkins  Hosp.  Bull.,  1896,  vol.  vii 
2G.  G.  Davis,  Ann.  Surg.,  Januarj',  1906. 


INGUINAL   HERNIA 


211 


usually  seen  in  one  of  two  forms.     One  form  pushes  its  way  through  the 
conjoiiKMl  tendon  and  comes  out  at  the  external  rins;.     This  hernia  is 


Fig.  119. — Halsted's  operation.     Mattress  sutures  tied  (Kelty)- 


,'>K-g:  03 

Fig.  120. — Halsted's  operation.     Suture  of  external  oblique  aponeurosis  (Kelly). 

covered  with  the  structures  I  have  already  described  in  discussing  the 
anatomy.  The  other  form  of  direct  hernia  bulges  around  the  outer  or 
lower  edge  of  the  conjoined  tendon  and  gradually  decreases  in  size  as 


212  THK    AHDO.MKN' 

it  extends  outward  toward  the  deep  ejjigastj-ic  artery.  In  dealing  with 
this  form  of  direct  hernia  one  may  employ  Bloodgood's  rectus  trans- 
plantation method  already  desci'ibed. 

In  the  case  of  the  first  form  of  direct  hernia,  the  form  covered  l)y  the 
conjoined  tendon  and  other  structures,  Davis  advises  a  plastic  opera- 
tion, employing  the  conjoined  tendon  alone,  and  I  have  used  this  method 
successfully  in  two  cases.  Davis's  method  consists  in  dividing  the  con- 
joined tendon  transversely  and  sewing  it  uj)  by  the  overlapping  flap 
method.  As  a  general  rule,  however,  transplantation  of  the  rectus  has 
proved  itself  a  satisfactory  measure  in  these  cases  also.  In  all  these  her- 
nia operations  avoid  damage  to  the  iliac  vessels,  which  are  surprisingly 
near  the  wound.     I  have  seen  the  vein  pricked  open. 

So  great  is  the  number  of  writer's  on  the  subject  of  inguinal  hernia, 
and  so  numerous  are  their  methods,  that  I  feel  impelled  to  name  some 
of  them. 

Czerny,  in  1877,  closed  the  sac  and  inguinal  ring.  He  dropped  back 
the  sac  and  sewed  the  pillars  of  the  ring  together.  Kiister  included 
the  floor  and  wall  of  the  canal  in  his  operation.  Championniere  split 
up  the  external  oblique.  Hall  and  Barker  modified  the  treatment  of 
the  sac  by  twisting  it  and  stitching  it  into  the  wound.  MacEwen  does 
not  cut  off  the  sac,  but  folds  it  up  into  a  pad  which  is  made  to  lie  in  the 
preperitoneal  space.  Bassini,  whose  method  is  the  basis  of  nearly  all 
modern  operations,  employs  the  maneuver  I  have  described  in  detail, 
transplanting  the  cord  and  isolating  the  sac  at  its  neck,  stripping  it 
back  to  a  distance  from  the  ring.  Wolfler  has  transplanted  the  cord  bj^ 
passing  the  testicle  through  the  space  between  the  two  recti  muscles, 
and  I  have  employed  a  similar  method,  passing  the  testicle  through  the 
conjoined  tendon,  but  long  ago  abandoned  it.  Kocher  transplants  the 
sac  entire,  slipping  it  under  the  external  oblique  and  bringing  it  out  well 
outside  of  the  internal  ring.  Schede  buries  silver  wire  sutures  deeply. 
Witzel  has  used  buried  wire  netting,  while  Trendelenburg  and  Kraske 
have  made  a  bone-flap  which  is  turned  upward  from  the  pubes.  "\\'.  S. 
Halsted,  who  shares  with  Bassini  the  honors  of  the  best  advanced 
work  on  inguinal  hernia,  published  in  1903  an  elaborate  essay  on  his 
completed  operation.  In  addition  to  the  details  I  have  already  des- 
cribed, he  makes  a  point  of  using  the  cremaster  muscle  to  strengthen  the 
scar  in  cases  of  long-standing  and  difficult  hemise.  He  ligates  the  sac 
at  the  highest  possible  point  by  transfixion  or  by  a  purse-string  suture, 
and  after  tying  this  suture,  carries  out  both  ends  under  the  internal 
oblique  nmscle,  and  passing  through  this  muscle  about  half  an  inch 
apart,  the  suture  ends  are  then  tied.  The  princi])le  is  similar  to  that  of 
Kocher.  Both  the  deep  stitches  and  the  stitches  of  the  external  oblique 
are  so  passed  as  to  effect  an  overlapping  of  the  appropriate  structures.^ 
Of  the  many  writers  upon  the  subject  of  inguinal  hernia  I  mention 
Kingscote,  Bishop,  Phelps,  Rotter,  Frank.  Ferrari,  Magnai,  Postenski, 
Girard,  Coley,  McBurney,  Ferguson,  and  Fowler,  whose  contributions  are 
well  summed  up  in  Dennis'  and  von  Bergmann's  Systems  of  Surgery. 
1  Johns  Hopkins  Hosp.  Bull.,  1903,  vol.  xiv,  p.  208. 


FEMOKAL   HERNIA  213 

The  after-treatment  of  these  cases  of  hernia  is  important.  The 
general  routine^  is  that  wliich  follows  any  clean  aljtloniinal  section,  but 
inasmuch  as  a  sound  closure  of  a  rupture,  long  open,  is  essential  to  success, 
one  must  keep  the  patient  in  bed  rather  longer  than  ordinarily.  I  prac- 
tise rest  in  bed  for  seventeen  days,  then  have  the  patient  get  up  gradually, 
walk  about  at  the  end  of  a  month,  and  avoid  active  exercise  for  another 
month.  Allow  him  to  wear  a  truss  under  no  circumstances:  it  thins 
down  the  cicatrix  and  favors  a  recurrence  of  the  rupture.  Should  the 
patient  be  very  restless  during  the  first  three  days  and  put  a  strain  on 
the  wound  by  flexing  his  thigh,  I  dress  the  corresponding  leg  in  a  ham 
splint.  This  immobilizes  the  knee  and  keeps  the  leg  quiet.  The  best 
dressing  for  the  wound  is  a  cotton  and  gauze  cocoon  over  the  incision, 
reinforced  by  a  heavy  sheet-wadding  pad  held  in  place  with  a  firmly 
applied  spica  bandage  of  Canton  flannel,  which  should  be  basted  over  to 
keep  it  from  slipping. 

In  the  case  of  fat  persons  or  feeble  persons,  or  if  there  be  excessive 
postoperative  oozing  which  cannot  be  checked,  it  is  well  to  leave  a 
cigaret  drain  in  the  lower  angle  of  the  wound,  and  remove  it  twenty-four 
hours  after  the  operation.  These  general  directions  for  after-treatment 
apply  to  both  forms  of  inguinal  hernia  and  to  femoral  hernia. 

Inguinal  hernia  in  women  is  one  of  the  easiest  hernise  to  cure.  The 
condition  is  not  very  common,  and  may  be  mistaken  for  femoral  hernia, 
but  a  careful  study  of  the  position  of  the  neck  of  the  sac,  and  its  rela- 
tion to  the  pubic  spine  and  to  Poupart's  ligament,  will  enable  the  practi- 
tioner to  distinguish  the  two.  A  large  inguinal  hernia  in  a  woman  will 
descend  into  and  fill  up  the  corresponding  labium  majus,  just  as  the 
large  hernia  in  man  descends  into  the  scrotum. 

In  operating  upon  inguinal  hernia  in  woman  the  question  of  dealing 
with  the  cord  is  practically  eliminated.  The  round  ligament  in  the 
female  corresponds  to  the  cord  in  the  male.  The  various  steps  already 
described  are  followed,  except  that  the  cord  need  not  be  transplanted, 
but  may  be  secured  within  the  stitches  which  attach  the~ conjoined  ten- 
don to  Poupart's  ligament.  The  surgeon  must  be  careful  not  to  cut 
off  the  round  ligament,  else  its  stump  wall  slip  back  behind  the  internal 
ring,  and  by  so  much  will  weaken  the  uterine  supports. 

FEMORAL   HERNIA 

As  the  inguinal  portion  of  the  abdominal  wall  is  weakened  b}^  the 
inguinal  rings  and  canal,  so  the  neighboring  region  below  Poupart's 
Hgament  is  weakened  by  the  passage  of  the  femoral  vessels  from  behind 
the  peritoneum  into  the  thigh.  A  glance  at  the  figure  shows  how  the 
crural  artery  and  vein  lie  in  their  separate  sheaths,  and  how,  between  the 
vein  and  Gimbemat's  ligament,  there  is  an  opening  known  as  the  fem- 
oral ring.  This  ring  is  patent  except  for  a  stray  lymph-node,  and  into 
the  ring  a  hernial  pouch  from  the  abdomen  may  protmde.  This  is  the 
common  form  of  femoral  hernia,  though  very  rarely  a  hernia  may  en- 
gage at  some  other  weak  point,  at  an  opening  in  Gimbemat's  ligament, 


214 


THE   ABDOMEN 


or  along  the  sheaths  of  the  vessels.  These  femoral  hemiae,  when  small, 
appear  as  mere  bulgings  h(>lo\v  Poupart's  ligament,  but  if  they  press  on- 
ward, they  burrow  l)eneath  the  fascia  lata  until  they  reach  the  weak 
cribriform  fascia  at  the  saphenous  opening,  when  they  protrude  beneath 
the  falciform  ])rocess  antl  appear  as  large  swellings  in  Scarpa's  triangle. 

The  dangers  and  incon\-eniences  of  these  hernial  are  such  as  I  have 
already  described.  Femoral  hernia  is  a  common  form  of  hernia  in 
women;  it  is  rare  in  men.  A  femoral  hernia  may  be  supported  by  a 
truss,  but  with  more  difficulty  and  discomfort  than  is  the  case  with  in- 
guinal hernia. 

The  operative  treatment  of  femoral  hernia  has  been  much  debated, 
and  sundry  procedures  are  advocated,  but,  on  the  whole,  we  cannot  feel 
sure  of  curing  these  herniae  as  we  feel  in  the  case  of  inguinal  hernia?. 


Fig.  121. — 1,  Poupart's  ligament;  2,  femoral  ring;  3,  Gimbemat's  ligament. 

During  the  past  five  years  I  have  used  the  method  advocated  by  C.  H. 
Mayo,  Ochsner,  and  others,  and  feel  that  our  evidence  of  its  value  is 
strong.  Make  a  five-inch  incision  one  inch  below  and  parallel  to  Pou- 
part's ligament.  Expose  the  sac  and  free  it  thoroughl}'  well  up  into 
the  abdominal  cavity;  open  it  and  return  its  contents;  then  draw  it 
down,  ligate  it  as  high  as  possible,  and  cut  it  olT  short,  leaving  the  liga- 
ture ends  long.  Thread  each  long  end  into  a  needle  and  pass  these 
needles  up  from  within  the  abdomen  through  the  abflominal  wall,  and 
tie  them  outside  of  the  external  oblique,  Ih  inches  above  the  femoral 
canal.  This  secures  the  peritoneal  process  away  from  the  ring,  and 
prevents  the  stump  of  peritoneum  from  passing  into  the  canal  during  its 
healing.  The  canal  is  not  further  treated  except  to  clear  it  from  fat. 
The  superficial  wound  down  to  the  femoral  opening  is  then  closed  with 


UMBILICAL   HERNIA  215 

catgut,  except  that  the  skin  wound  is  sutured  with  superficial  horse- 
hair. On  first  thought,  and  in  view  of  the  elaborate  treatment  of  the 
canal  advocated  by  many  surgeons,  this  operation  sounds  ineffective; 
but,  in  fact,  the  femoral  ring,  relieved  of  the  pressure  of  the  hernia, 
closes  down  to  a  normal  size,  and  relapses  have  been  rare  in  a  large 
series  of  cases.  Here  three  weeks'  rest  in  bed  and  the  subsequent 
avoidance  of  a  truss  are  prescribed. 

Of  the  other  femoral  hernia  operations  I  mention  that  of  Bassini, 
who  ties  the  neck  of  the  sac,  cuts  it  off,  and  returns  it  into  the  belly, 
and  then  with  deep  sutures  attaches  Poupart's  ligament  to  the  pectineal 
aponeurosis  as  high  up  as  the  pectineal  eminence.  Kocher  performs 
an  operation  somewhat  similar  to  Ochsner's,  but  after  exposing  the  sac, 
instead  of  cutting  it  off,  he  inverts  it  on  the  point  of  a  forceps,  forces  it 
through  the  canal,  and  brings  it  out,  apex  first,  above  Poupart's  liga- 
ment, where  he  secures  it  beneath  the  skin.  He  sews  up  the  deep 
structures  in  much  the  same  fashion  as  does  Bassini.  NicoU  ^  describes 
an  interesting  and  elaborate  procedure:  after  opening  the  sac  he  splits 
it,  twists  the  neck,  and  interlocks  the  two  halves  by  buttonholing  one 
through  the  other.  He  then  reduces  the  sac  through  the  ring  into  the 
extraperitoneal  space,  and  causes  it  to  He  bunched  up  within  the  ab- 
domen, between  the  peritoneum  and  the  transversalis  and  iliac  fasciae, 
over  the  internal  aperture  of  the  femoral  canal.  He  then  closes  the 
femoral  ring  by  laying  bare  the  pubic  ramus  from  the  femoral  vein  to 
the  pubic  spine,  detaching  the  periosteum,  drilling  tw^o  holes  through 
the  ramus,  and  stitching  firmly  with  mattress  sutures  Poupart's  Hga- 
ment  to  the  ramus.  In  other  words,  he  closes  the  femoral  ring  by 
reinforcing  and  extending  into  it  Gimbernat's  Hgament.  Kammerer  - 
describes  a  further  elaborate  operation  advocated  b}^  Lotheissen  in 
1898  and  by  Gordon  in  1900;  that  is  but  another  added  to  the  Hst  of 
the  many  operations  proposed  by  many  surgeons.  Most  of  these  opera- 
tions are  designed,  and  rather  ineffectually  designed,  to  close  the  femoral 
canal.  The  simple  operation  I  described  at  first,  which  leaves  the  canal 
to  close  itself,  is  effective. 

UMBILICAL  HERNIA 

Umbilical  hernia  is  a  subject  which  we  may  divide  into — (1)  Con- 
genital hernia  of  the  cord;  (2)  umbilical  hernia  of  infants;  (3)  umbilical 
hernia  of  adults. 

1.  Congenital  hernia  of  the  cord  (ectopia  viscerum)  is  probably  a 
malformation  or  monstrosity,  and  is  due  to  a  faulty  closure  of  the  vitel- 
line duct.  A  large  part  of  the  abdominal  contents  may  protrude  through 
the  opening.  Sometimes  operative  measures  may  reduce  or  improve  the 
deformity,  but  the  condition  is  rare  and  should  be  studied  in  the  large 
treatises  on  surgery. 

1  Brit.  Med.  Jour.,  November  8,  1902;  Scottish  Med.  and  Surg.  Jour.,  December, 
1903:  Ann.  Surg.,  Januany,  1906. 

-  Frederick  Kammerer,  Ann.  Surg.,  Jime,  1904. 


216 


THE    A B DOM EX 


2.  Uttibilicdl  hcrnid  of  iiifdnls  is  due  to  failure  of  the  lunbilical 
ring  to  close  tightly  during  the  first  few  weeks  of  life.  A  w(>ak  spot  is 
thus  left  in  the  abdominal  wall,  and  a  small  hernia  may  protrude,  induced 
by  the  child's  crying  and  straining.  The  condition  is  extremely  com- 
mon in  infants,  but  rarely  results  seriously,  and  strangulation  is  a  remote 
curiosity.  This  hernia  in  infants  can  almost  always  })e  cur(>d  by  the  use 
of  a  light  support,  ^^'rap  a  penny  in  gauze;  press  it  down  upon  the  ring 
of  the  reduced  hernia,  and  strap  it  into  place  with  a  six-inch  strip  of 
adhesive  plaster  passed  over  the  belly.  Teach  the  nurse  to  reappl}'  the 
plaster  once  a  week.  This  usuall}'  will  cure  the  hernia  in  two  or  three 
months.  It  the  hernia  persists  as  the  child  grows  older,  a  specially 
constructed   padded   belt   may  be  worn  until   a  cure  is  effected.     If  it 

becomes  apparent  in  the  course  of  years 
that  the  ring  is  not  closing,  a  simple  radical 
operation  may  be  done.  Cut  down  longi- 
tudinally upon  the  hernia;  reduce  its  con- 
tents ;  open  the  sac ;  free  all  adhesions ;  loosen 
the  peritoneum  about  the  ring,  and  sew  the 
peritoneal  edges  together.  Then  excise  the 
ring  and  sew  up  the  abdominal  wall.  This 
operation  is  simple  and  effective.  The  after- 
treatment  needs  no  special  comment. 

3.  The  umbilical  hernia  of  adults  is  a  far 
more  complicated  affair  and  merits  careful 
consideration.  This  form  of  hernia  is  ten 
times  commoner  in  women  than  in  men. 
Unlike  the  umbilical  hernia  of  children,  it 
may  reach  an  enormous  size — as  large  or 
\  LU/  I  larger  than  a  man's  head,  and  the  ring  may 

\  11  /  be  as  much  as  three  inches  or  more  in  di- 

^  '  ameter.     Women  are  more  prone  to  it  than 

men,  on  account  of  the  more  sedentary  lives 
of  the  former  and  the  relaxation  of  their  ab- 
dominal muscles,  and  especially  from  the  ab- 
dominal distention  due  to  pregnancy  and 
large  pelvic  tumors.  The  hernia  grows  quite  rapidly.  Commonly,  it 
contains  omentum  and  small  intestine,  but  may  contain  omentum,  large 
intestine,  and,  rarely,  the  stomach  or  even  the  utems.  The  cover- 
ings of  these  hernise  are  thin  and  are  composed  of  little  besides  skin  and 
superficial  fascia,  so  that  the  hernial  sac,  protruding  between  the  recti 
muscles  through  the  umbilical  ring,  is  close  to  the  skin  and  often  adherent 
to  it.  These  hernise  are  frec[uently  irreducible,  but  rarely  become  stran- 
gulated. Owing  to  the  inevitable  friction  and  irritation  of  the  region, 
the  sac,  throughout  its  whole  extent,  may  become  adherent  to  the  skin 
and  the  viscera  to  the  sac. 

The  treatment  of  umbilical  hernia  may  be  the  wearing  of  a  truss 
belt  if  the  patient  chooses;  and,  in  the  case  of  feeble,  elderly  persons, 
such  palliative  treatment  is  the  only  reasonable  measin-e.     If  the  hernia 


Fig.  122. — Diagram  show- 
ing simple  method  of  retain- 
ing umbilical  hernia  in  an  in- 
fant. 


UMBILICAL   HERNIA 


217 


is  roduoiblo,  the  patient  may  thus  be  made  comfortable.     If  the  hernia 
is  irreducible,  lioAvever,  one  must  resort  to  a  radical  operation  unless  it  is 


Fig.  123. — Adult  umbilical  hernia  (Massachusetts  General  Hospital). 


Fig.  124. — Mayo's  operation,  showing  the  transverse  elliptic  incisions  and  exposure 
of   the   neck   of   the   sac    (W.   J.   Mayo). 

obvious  that  such  an  operation  will  endanger  life.  Until  recent  j^ears 
the  radical  cure  of  umbilical  hernia  was  unsatisfactory^,  for  the  method 
used  was  that  of  stitching  together  the  two  recti  muscles.     Muscles  are 


218 


THE    ABDOMEN 


weak  barriers.  In  these  cases  the  recti  are  worn-out,  flabby  structures, 
which  permit  the  hernia  to  relapse.  Aponeuroses  are  needed  for  the 
work.  Moreover,  the  great  ring  in  these  cases  is  almond  shaped,  with 
its  greatest  diameter  from  side  to  side.  A  satisfactory  operation  con- 
sists in  drawing  these  aponeuroses  together  and  overlapping  them  from 
above   downward.'       Make   transverse   crescentic   incisions   about   the 


Fig.  125. — Three  mattress  sutures  introduced  CW.  J.  Mayo). 

hernia  and  expose  the  base  of  the  sac;  then  clear  thoroughly  by  gauze 
dissection  the  aponeuroses  for  two  or  three  inches  around  the  neck  of 
the  sac.  Cut  away  the  fibrous  and  peritoneal  coverings  of  the  hernia, 
return  viscera  to  the  abdomen,  and  cut  away  redundant  omentum. 
Enlarge  the  ring  transversely  for  one  or  two  inches  at  either  lateral  end  of 
the  hernial  ring,  and  strip  back  the  parietal  peritoneum  for  an  inch  or 


Fig.  126. — Mattress  sutures  tied  above,  and  upper  edge  of  incision  stitched  to  surface 
of  aponeurosis  below  (W.  J.  Mayo). 

two.  Our  purpose  next  is  to  slip  the  lower  aponeurotic  edge  of  the  ring 
beneath  the  upper  edge — between  it  and  the  peritoneum.  Pass  a  suffi- 
cient number  of  wire  or  silk  mattress  sutures  from  the  lower  to  the 
upper  flap,  but  before  tying  them,  make  upon  them  tension  sufficient  to 

1  W.  J.  Mayo,  Jour.  Amer.  Med.  Assoc,  July  25,  1903;  J.  C.  Warren,  Boston  Med. 
and  Surg.  Jour.,  October  S,  1903. 


VENTRAL  HERNIA 


219 


bring  together  the  underlying  peritoneal  edges.  Sew  up  the  peritoneum 
with  a  running  catgut  stitch.  Then  fix  the  mattress  sutures,  and  tack 
down  the  free  upper  edge  to  the  lower  aponeurosis  with  a  buttonhole 
catgut  stitch.  Close  the  skin  wound  by  your  usual  method.  In  the 
case  of  very  fat  persons,  with  pendulous  abdomens,  I  have  seen  J.  C. 
A^'arren  excise,  in  addition,  a  great  mass  of  adipose  tissue,  hke  the  section 
of  an  orange,  across  and  across  the  abdomen  below  the  navel.  This 
relieves  the  strain  over  the  fresh  umbilical  wound,  and  seems  to  offer 
a  better  chance  *of  permanent  cure.  In  the  after-treatment  the  ab- 
domen should  be  supported  in  a  well-fitting  swathe  for  at  least  four 
months.^ 

VENTRAL  HERNIA 

Ventral  hernia  is  a  hernia  through  the  abdominal  wall  at  some 
point  not  normally  w^eak ;  through  the  linea  alba,  above  or  below  the 
navel;  through  the  linese  semilunares,  etc.  Writers  distinguish  hernia 
jpara-umhilicalis  and  hernia  epigastrica. 
The  causes  of  these  hernise  are  a  weak- 
ening of  the  wall  at  the  point  affected 
— congenital,  pathologic,  or  traumatic. 
Usually  the  anatomy  of  the  hernia  is 
similar  to  that  of  umbilical  hernia,  but 
sometimes  the  peritoneal  sac  is  partially 
or  entirely  lacking.  Many  of  these 
hernise  are  of  great  interest.  Epigas- 
tric hernia  is  rather  common.  It  pro- 
trudes through  weakened  portions  of 
the  interlocldng  aponeurotic  fibers  in 
the  median  line,  and  gives  rise  to  trains 
of  obscure  gastro-intestinal  symptoms, 
especially  colicky  pains.  Portions  of 
omentum  become  caught;  trifling  pain- 
ful swellings  come  and  go,  but  the 
hernia  rarely  reaches  a  great  size.- 
Another  interesting  hernia,  unfortun- 
ately too  common,  is  "  hernia  in  a 
scar,"  a  weak  point  due  to  imperfect 
closure  of  the  w^ound  after  an  abdom- 
inal section.  This  hernia  is  most  com- 
mon as  a  sequel  of  the  operation  for 
acute  appendicitis,  but  we  see  it  in  all 
parts  of  the  abdominal  wall. 

The  treatment  of  ventral  hernia  is  often  difficult.  The  simple 
reducible  protrusion,  with  a  complete  sac,  is  easily  cared  for,  but  the 
extensive  hernia,  irreducible,  adherent,   with  numerous  sacculations, 

1  See  W.  J.  Mayo,  Radical  Cure  of  Umbilical  Hernia,  Jour.  Amer.  Med.  Assoc, 
June  1,  1907. 

2  H.  A.  Lothrop,  Boston  Med.  and  Surg.  Jour.,  March  4,  1897:  D.  D.  Stewart, 
Amer.  Med.,  July  29,  1905. 


.  127.— Bartlett's    filligree 
the  cure  of  ventral  hernia. 


for 


220  THE    ABDOMEN 

commits  the  surgeon  to  a  long,  laboiious,  painstaking  dissection.  The 
aponeurosis  must  be  widely  exposed  for  ease  in  sewing  up ;  all  adhesions 
must  be  freed;  prolapsed  and  adherent  omentum  must  be  excised,  and 
the  viscera  must  be  returned  to  the  abdomen,  leaving  a  free  border  of 
peritoneum  on  either  side  of  the  ring.  The  ring  is  often  enormous;  its 
edges  must  be  refreshed;  the  various  layers  identified  and  separated, 
and  repair  of  the  ring  must  be  made  by  carefully  placed  layers  of  stitches 
— silk  or  catgut — bringing  the  corresponding  structures  together  from 
either  side.  The  approximation  of  the  aponeuroses  must  be  made  by 
overlapping,  for  by  overlapping  is  a  firm  scar  best  secured.  The  patient 
must  wear  a  well-fitting  abdominal  binder  or  belt  for  at  least  six  months 
after  most  of  these  operations,^ 

DIAPHRAGMATIC  HERNIA 

Diaphragmatic  hernia  occurs  occasionall}'.  It  maj'  be  due  to  con- 
genital defects  in  the  diaphragm,  through  which  the  abdominal  contents 
escape  into  the  thorax;  or  to  wounds,  accidental  or  inflicted  during  the 
course  of  an  operation  upon  the  chest-wall;  for  be  it  remembered  that  the 
lateral  and  dorsal  portions  of  the  diaphragm  arch  up  along  the  chest- 
wall  as  far  as  the  fifth  rib,  on  expiration,  leaving  a  narrow  space  only 
between  parietal  pleura  and  diaphragm.  The  operator  may,  therefore, 
easily  penetrate  the  abdomen  if  he  open  hastily  through  the  lower  part 
of  the  chest-wall.  Diaphragmatic  hernia  may  or  tiiay  not  be  covered 
with  peritoneum  in  the  form  of  a  sac. 

The  symptoms  of  this  form  of  hernia  are  difficult  and  obscure,  for 
they  point  to  both  a  thoracic  and  an  abdominal  lesion.  There  are 
dyspnea,  palpitation,  and  pain  in  the  chest.  There  are  gastro-intestinal 
symptoms,  pain,  flatulence,  and  constipation;  the  pain  is  usually  in  the 
epigastrium.  A  physical  examination  may  reveal  tympany  high  in  the 
chest  and  a  displaced  heart.  Sometimes  the  x-ray  will  show  the  lungs 
crowded  up  and  the  heart  in  an  abnormal  position.  Diaphragmatic 
hernia  may  become  strangulated,  in  which  case  the  symptoms  are  those 
of  an}'  other  strangulation  of  the  abdominal  viscera. 

The  treatment  of  strangulated  diaphragmatic  hernia  is  obviously 
to  open  the  abdomen,  reduce  the  hernia,  and  treat  the  viscera  as  the  con- 
dition indicates.  Hitherto  no  operation  is  reported  as  performed  upon 
non-strangulated  diaphragmatic  heniia.  The  permanent  closure  of  the 
ring  in  the  diaphragm  is  a  difficult  matter,  for  when  closed,  it  is 
wont  to  open  again  and  the  hernia  to  return.  The  best  suggestion 
hitherto  made  is  to  sew  the  stomach  with  two  or  three  rows  of  stitches 
against  the  diaphragm  and  over  the  repaired  ring. 

Gluteal  and  sciatic  hernioe  are  rare  forms  of  hernia  which  protrude 
respectivel)^  through  the  greater  and  lesser  sciatic  notches — natural 
openings  separated  by  the  small  sciatic  ligament.  When  one  of  these 
hemise  becomes  large,  so  as  to  be  distinctly  recognizable,  it  forms  a  tumor 

^  Bartlett's  silver  wire  filligree  buried  beneath  the  aponeurosis  streng:thens  the 
wound. 


RETROPEKITONEAL  HERNIA 


221 


eovering  in  the  anal  region  and  extending  toward  the  median  Hne. 
These  hernia;  rarely  become  strangulated,  but  when  the  symptoms  are 
urgent,  the  surgeon  must  cut  down  upon  the  mass  and  follow  it  up  into 
the  sciatic  notch  in  order  to  reduce  and  cure  it. 

OBTURATOR   HERNIA 

About  200  cases  of  obturator  hernia  have  been  reported.  These 
hernise  are  found  chiefly  in  old  women,  and  are  often  associated  with 
hernise  in  other  regions.  They  appear  as  swellings  at  the  upper  por- 
tion of  the  adductor  longus,  internal  to  the  femoral  vessels.  Make  the 
examination  with  the  thigh  flexed,  adducted,  and  rotated  outward. 
The  diagnosis  is  not  easy.  The  hernia  has  never  been  operated  upon 
hitherto  except  when  strangulated.  The  results  of  operation  are  un- 
favorable, for  it  is  extremely  difficult  to  make  the  deep  dissection  and 
properly  to  treat  the  diseased  bowel.  I  suggest  that  after  loosening 
the  sac  and  freeing  the  neck  it  would  be  well  to  open  the  abdominal 
cavity  from  above  and  handle  the  viscera  from  this  point  of  vantage. 


RETROPERITONEAL  HERNIA 

There  are  various  forms  of  retroperitoneal  hernia — hernia  which 
burrows  behind  normal  inoffensive  looking  peritoneal  bands  and  folds. 


Fig.  128. — Site  of  retroperitoneal  hernia. 

J.  B.  Blake  has  described  four  such  hernise  about  the  head  of  the  cecum, 
and  Moynihan  has  written  an  elaborate  work  on  the  subject,  in  which  he 
deals  especially  with  duodenal  hernia — hernia  through  the  foramen  of 
Winslow  and   behind  the  duodenum.      Hernia  escapes  also   through 


222  THE   ABDOMEN 

abnormal  openings  in  the  mesentery  and  the  broad  ligaments.  Both 
Mo^^lihan  and  A^^  J.  Mayo  describe  a  jejunal  hernia  in  the  neighborhood 
of  a  gastro-enterostomy  operation  field.  Obviously,  all  these  forms  of 
internal  hernia  are  impossible  of  exact  diagnosis.  The  symptoms  arc 
those  of  intestinal  strangulation,  for  which  the  surgeon  must  operate; 
he  must  treat,  on  general  principles,  the  viscera  as  well  as  the  hernial 
opening,  and  according  to  the  conditions  which  he  discovers. 

Glancing  back  over  the  general  subject  of  abdominal  hernia,  one 
observes  that  certain  forms  are  common,  and  that  other  forms  are  ex- 
tremely rare;  that  the  whole  subject  is  a  subcHvision  of  intestinal  surgery; 
that  strangulation  is  the  possible  serious  outcome  in  all  cases,  and  that 
a  proper  broad  rule  is  to  relieve  and  repair  all  hernia?  wherever  found. 


CHAPTER  VIII 

PERITONEUM  AND  RETROPERITONEAL  SPACE 

The  subject  of  the  peritoneum  is  one  of  the  most  difficult  and  intricate 
in  surgery.  The  anatomy  of  the  peritoneum  is  puzzhng,  its  diseases 
are  often  obscure,  and  their  treatment  has  been  a  matter  of  hot  debate. 
When  you  find  the  treatment  of  a-  disease  debated  and  opposing  views 
taken  almost  with  acrimony  by  competent  men,  you  may  assume  fairly 
that  the  end  is  not  yet.  The  best  one  can  do  is  to  adopt  that  course 
which  appears  to  be  supported  by  the  greatest  weight  of  rational  opin- 
ion, provided  it  agrees  with  one's  own  sense  of  the  rational  and  one's 
own  experience.  Generally,  in  the  case  of  constantly  debated  subjects, 
you  will  find  in  the  course  of  time  that  the  best  men  are  drifting  toward 
definite  and  similar  conclusions,  however  far  apart  they  may  have 
wandered. 

The  peritoneum  is  a  serous  membrane  forming  a  cavity,  and  this 
cavity  has  been  likened  to  a  great  lymph-sac.  Its  surface  is  extensive, 
probably  somewhat  greater  than  that  of  the  skin  of  the  whole  body. 
It  is  a  closed  cavity  in  man;  in  woman  it  communicates  through  the  Fal- 
lopian tubes  with  the  outer  world.  It  has  a  great  capacity  for  absorp- 
tion, especially  in  the  diaphragmatic  region,  where  the  stomata  in  the 
central  portion  of  the  diaphragm  drink  up  fluid  with  great  rapidity. 
When  irritated,  the  peritoneum  throws  out  rapidly  a  copious  exudate, 
which  may  be  fibrinous  and  cause  adhesions  of  the  serous  surfaces;  or 
the  exudate  may  be  a  fluid,  rich  in  albumin,  and  easily  changed  in  char- 
acter, or  it  may  be  seropurulent.  Owing  to  these  peculiarities,  the 
peritoneum  may  become  rapidly  involved  in  dangerous  infections;  at 
the  same  time,  it  has  remarkable  powers  of  recuperation.  Its  nicely  ad- 
justed mechanism  resents  irritation,  but  it  can  dispose  of  an  immense 
volume  of  poison.  Our  greatest  interest  in  the  peritoneum  centers, 
therefore,  in  'peritonitis,  of  which  there  are  various  forms — acute,  chronic, 
tuberculous,  and  malignant  being  the  most  important.  Moreover, 
there  are  diseases  of  the  retroperitoneal  space— infections  with  their 
resulting  inflammations  and  abscesses,  diseases  of  the  lymph-nodes,  and 
tumors. 

Injuries  of  the  peritoneum  make  up  another  subject  of  broacl  general 
interest,  which  we  have  discussed  already  when  we  were  dealing  with 
injuries  and  special  diseases  of  the  abdomen. 

ACUTE  PERITONITIS 

Acute  peritonitis  is  divided  anatomically  into  localized  and  diffuse 
peritonitis.     I  have  treated  of  the  former  in  describing  certain  forms 

223 


224  THE   ABDOMEN 

of  appendicitis.  Similar  forms  of  localized  ])oritonitis  may  develop  about 
an}'  diseased  organ,  as  the  Fallopian  tubes,  gall-bladder,  duodenum, 
stomach,  etc.  This  limited  peritonitis  results  in  an  exudate  of  fibrinous 
character,  which  mats  together  neighboring  organs,  and  locks  up  in 
separate  pockets  the  secretions  as  they  are  ])roduced.  Colon  bacilli, 
streptococci,  and  staphylococci  are  the  organisms  commonly  concerned 
in  these  restricted  inflammations,  though  pneumococci  and  other  rare 
organisms  sometimes  arc  found.  The  symptoms  are  variable  and 
depend  on  the  extent  and  duration  of  the  disease,  as  well  as  upon  its 
point  of  origin.  There  are  localized  pain  and  tenderness,  a  fluctuating 
temperature,  rareh'  high ;  sometimes  nausea,  and  rarel}-  vomiting,  though 
there  is  usually  distaste  for  food.  Thei'e  may  be  occasional  chills; 
constipation  is  common,  but  absolute  obstruction  is  rare. 

The  diagnosis  of  any  localized  peritonitis  is  based  upon  finding 
within  the  abdomen  a  mass,  usually  tender,  varying  in  size  and  con- 
sistence, of  recent  origin,  and  associated  with  chills,  fever,  a  quickened 
pulse,  general  abdominal  discomfort,  with  malaise,  dyspepsia,  and  con- 
stipation. This  mass  represents  often  an  accumulation  of  fluid,  which 
may  remain  pocketed  for  a  long  time ;  it  may  become  absorbed  or  it  may 
spread — sometimes  into  the  general  peritoneal  cavity;  sometimes  into 
neighboring  hollow  organs;  sometimes  by  burrowing  through  the  skin. 
When  such  a  mass  or  focus  is  discovered,  it  should  be  opened  and  drained. 
When  its  presence  is  suspected  but  the  mass  is  not  definitely  located, 
one  should  explore  for  it. 

One  of  the  serious  results  of  localized  peritonitis  is  the  formation 
of  chronic  adhesions,  which  may  persist  and  cause  great  subsec[uent 
functional  trouble.  I  shall  refer  to  the  treatment  of  these  adhesions 
when  we  come  to  the  subject  of  chronic  peritonitis. 

Subphrenic  peritonitis  and  abscess  is  a  special  and  interesting  form 
of  localized  peritonitis.  It  may  be  due  to  extension  from  disease  of  the 
pleura,  of  the  liver,  or  of  the  gall-bladder,  and  may  be  confined  closely 
to  the  vicinity  of  the  diaphragm,  and  be  within  the  greater  peritoneal  sac, 
A  more  important  and  interesting  form  of  subphrenic  peritonitis  is  that 
which  appears  within  the  lesser  peritoneal  sac,  behind  and  below  the 
stomach  and  the  anterior  layers  of  the  great  omentum.  The  source  of 
infection  may  be  a  perforation  of  the  posterior  portion  of  the  stomach, 
the  duodenum,  or  colon  or  an  acute  inflammation  of  the  pancreas. 
There  results  a  distention  of  the  lesser  sac,  with  the  appearance  of  a 
tumor  above  the  umbilicus.  The  colon  always  lies  below  this  tumor, 
and  never  in  front  of  it,  as  is  the  case  in  enlargement  of  the  kidney. 
Osier  mentions  a  remarkable  form  of  subphrenic  abscess  containing  air, 
called  by  Leyden  pyopneumothorax  subphrenicus.  The  symptoms  in 
all  these  cases  are  those  of  acute  localized  intra-abdominal  inflammation. 
When  in  the  neighborhood  of  the  diaphragm,  the  abscess  may  be 
reached  either  from  the  front  or  back  and  may  be  walled  off  and  drained 
successfully.  Abscess  of  the  lesser  sac  is  best  reached  through  the  gastro- 
colic omentum;  but  hitherto  operation  in  this  disease  has  been  followed 
by  a  considerable  mortality. 


ACUTE    PERITONITIS  225 


DIFFUSE  Peritonitis 

Diffuse  peritonitis  (general  peritonitis,  so  called)  is  the  great  topic 
with  which  we  have  to  deal  in  this  chapter.  The  pathologic  appeai-ances 
of  diffuse  peritonitis  vary  in  different  patients,  and  in  the  same  patient 
even,  so  that  one  portion  of  the  abdominal  cavity  may  differ  in  appear- 
ance from  another.  The  progress  of  the  disease  is  influenced  both  by 
gravity  and  by  the  lymphatic  arrangements — for  instance,  the  peri- 
tonitis which  results  from  a  perforating  duodenal  ulcer  advances  rapidly 
down  the  right  flank,  as  the  septic  material  descends  by  the  side  of  the 
spinal  column,  over  the  right  kidney,  and  ascending  colon,  toward  the 
pelvis.  Peritonitis  starting  from  the  appendix  spreads  at  first  into  the 
pelvis,  then  extends  around  on  to  the  left  side,  involving  gradually  the 
sigmoid,  left  renal,  and  splenic  regions.  At  the  same  time  it  extends 
more  slowly  toward  the  liver,  so  that  active  organisms  will  be  found  in 
varying  numbers  in  these  places,  while  in  the  center  of  the  abdomen  there 
may  be  no  organisms  whatever,  but  nearly  always  an  abundant  exudate, 
rich  in  toxins.  Von  Mikulicz  wrote  a  paper,  often  quoted,  and  des- 
cribed three  forms  of  diffuse  peritonitis — diffuse  septic,  gangrenopurulent, 
and  fibrinopurulent.  You  cannot  alw^ays  distinguish  these  with  cer- 
tainty, save  postmortem.  In  practice,  the  appearance  of  the  exu- 
date and  of  the  peritoneum,  the  extent  and  rapiditj^  of  effusion,  and 
the  constitutional  reaction  of  the  patient  determine  for  j^ou  the  gravity 
of  the  condition. 

Writers  still  talk  about  idiopathic  peritonitis — an  archaic  term, 
which  should  find  no  place  in  our  vocabulary.  Sometimes  we  fail  to 
isolate  organisms  from  the  abdomen  in  certain  cases  of  diffuse  perito- 
nitis; but  we  may  be  certain  that  organisms  somewhere  are  present, 
even  though  we  fail  to  find  them. 

A  chemical  or  traumatic,  non-infecting  form  of  peritonitis  frequently 
occurs,  but  is  always  strictly  limited,  and  is  properly  a  reaction  of  the 
peritoneum — a  process  of  repair  following  some  injury,  such  as  the  inser- 
tion of  a  drainage-tube  or  wdck,  rough  handling,  the  twisting  of  an 
ovarian  tumor.  These  simple  forms  of  peritonitis  generally  result  harm- 
lessly if  prompt^  relieved,  except  in  so  far  as  they  may  give  rise  to 
adhesions  destined  to  make  trouble. 

Diffuse  infectious  peritonitis  agitates  us  especially.  The  sources  of 
infection  have  been  detailed  already.  The  most  virulent  organisms 
come  from  the  intestinal  tract,  and  Harvey  Gushing  long  ago  showed 
that  the  upper  portions  of  the  canal  have  relatively  few  bacteria;  that 
the  ileum  has  the  greatest  number,  while  there  is  a  sudden  drop  after 
passing  the  ileocecal  valve.  Besides  the  intestinal  canal,  from  which 
bacteria  may  escape,  there  is  the  possibility  of  infection  spreading  from 
disease  of  the  ischiorectal  fossa  and  of  the  genito-urinary  apparatus^ 
and  from  penetrating  wounds.  The  following  table  is  interesting: * 
1  Von  Bergmann's  System  of  Surgery,  vol.  iv,  p.  165. 


15 


226  THE   ABDOMEN 

SOURCES   OF   PERITONITIS   IN   446   CASES 

Appendicitis 115 

Stoniuch  Jiml  cluodi-nuin 68 

The  rest  of  the  intestines 118 

Female  genitals 81 

Gall-bladder 10 

Kidney  and  urinary  bladder 10 

Pancreas 2 

Spleen 1 

I'nknown 35 

Post-operative 4 

Hematogenous  origin  (nephritis,  etc.) 2 

These  infections  are  most  commonly  due  to  colon  bacilli,  then  to 
streptococci,  staphylococci,  and,  more  rarely,  gonococci,  pneumococci, 
gas-forming  bacilli,  and  a  few  other  rare  organisms.  The  infection  is 
usually  mixed.  According  to  the  predominance  of  one  or  other  of  these 
organisms  the  progress  of  the  disease  is  slow  or  rapid,  and  the  morpho- 
logic appearances  differ.  The  colon  bacillus  sometimes  produces  but 
slight  irritation,  even  with  a  considerable  seropurulent  exudate,  but  oc- 
casionally it  may  produce  an  extensive  irritating  effect,  causing  a  rapid 
distention  of  the  cells  of  the  peritoneum  and  occasionally  gangrene  even. 
Staphylococci  cause  a  rapid  fibrinous  exudation  with  an  abundant 
deposit;  for  this  reason  the  cjuantity  of  pus  in  the  cavity  is  usuall}-  small, 
but  w^hen  it  is  large,  it  is  of  the  seropurulent  type.  Streptococci  give 
rise  to  little  if  any  free  pus,  and  the  peritoneum  has  a  peculiar  dry, 
granulated,  blistered  appearance.  As  a  rule,  however,  with  mixed  in- 
fections in  which  the  colon  bacillus  predominates  there  is  an  abundant 
secretion  of  fluid,  the  peritoneal  cavity  containing  many  ounces  of  a 
rather  thin,  turbid  material,  with  occasional  patches  of  agglutination 
and  excoriation,  but  with  a  variety  of  appearances  in  different  portions 
of  the  abdomen. 

Symptoms. — The  symptoms  of  diffuse  peritonitis  are  as  various 
as  are  the  pathologic  appearances.  One  must  consider,  first,  the  initial 
disturbance — appendicitis,  or  whatever  it  may  be — such  disturbances 
as  I  have  already  described  in  detail.  The  localized  symptoms  due  to 
these  special  lesions  extend  gradually  as  the  inflammation  extends  until 
the  symptoms  and  signs  become  wide-spread  as  large  areas  of  the  peri- 
toneum are  involved.  In  general  terms  there  are  superadded  to  the 
intense  initial  abdominal  pain  chilly  feelings  or  an  actual  rigor.  The 
pain  extends  over  the  abdomen  and  is  aggravated  by  pressure  and  by 
moving.  The  patient  lies  on  his  back  and  tries  to  relieve  the  tension  by 
drawing  up  his  knees  and  having  his  shoulders  raised.  He  breathes  in 
a  shallow,  rapid  fashion  of  the  costal  type,  because  contraction  of  the 
diaphragm  increases  his  pain.  He  holds  his  abdominal  muscles  rigidly 
contracted  in  order  to  keep  at  rest  the  inflamed  pei'itoneum.  Clradually, 
the  abdomen  becomes  distended,  tense,  and  tj'mpanitic;  the  pulse  rapid, 
small,  hard,  and  wiry,  ranging  from  110  upward.  The  temperature  may 
rise  to  103°,  104°,  and  105°  F.  after  a  chill,  but  its  average  elevation  is 
moderate.  With  collapse  or  later  in  the  disease  it  becomes  subnormal. 
The  tongue,  at  first  white  and  moist,  becomes  dry,  red,  and  cracked. 


ACUTE    PEKITOXITIS  227 

Nausea  and  vomiting  appear  early,  and  vomiting  causes  great  pain.  The 
patient  ejects  first  the  <;a.stri('  eontents,  then  a  yellowish  and  bile-stained 
fluid,  then  a  greenish  lluid,  and  often,  late  in  the  disease,  a  brownish- 
black  liquid,  broken-down  blood  with  a  fecal  odor — the  contents  of  the 
small  intestine.  There  may  be  an  initial  diarrhea,  but  constipation 
rapidly  ensues.  Sometimes  there  is  frequent  micturition;  less  often, 
retention.  The  urine  is  scanty,  high  colored,  and  with  a  large  quantity 
of  indican. 

The  facial  expression  is  the  Hippocratic  facies  I  have  described  before 
— "a  sharp  nose,  hollow  eyes,  collapsed  temples;  the  ears  cold,  contracted, 
and  their  lobes  turned  out;  the  skin  about  the  forehead  being  rough, 
distended,  and  parched;  the  color  of  the  face  being  brown,  black,  livid, 
or  lead  colored"  (Sir  James  Paget). 

When  you  come  to  the  physical  examination,  you  will  find  two  dis- 
tinct types  of  abdomen — the  distended  and  the  retracted.  The  dis- 
tended abdomen  is  the  more  conmion.  It  may  be  enormously  swollen, 
drum-like,  very  tense,  glistening,  slightly  reddened;  everywhere  tym- 
panitic, even  over  the  hepatic  and  splenic  areas;  too  exquisitely  tender 
for  satisfactor}^  palpation;  often  the  recti  muscles  show  spasm  on  being 
irritated.  Fluid  may  be  made  out  in  the  flanks — fluid  which  shifts  as 
the  patient  turns.  Rarely  the  abdomen  may  be  flat  and  board-like  if 
there  be  no  exudation  and  but  slight  intestinal  distention  in  the  case  of  a 
rapidly  progressive  infection. 

Most  cases  of  diffuse  peritonitis  proceed  to  a  termination  in  death. 
The  severe  forms  may  kill  within  forty-eight  hours,  but  more  commonly 
the  disease  lasts  four  or  five  days.  When  the  patient  dies  early,  he  dies 
from  a  rapid,  overwhelming  toxemia.  If  he  lingers,  he  dies  from  a 
slow  toxemia,  in  profound  depression,  in  a  low  muttering  delirium,  with 
lijjs  blue,  extremities  cold  and  clammy,  the  pulse  irregular,  the  heart- 
sounds  weak,  the  breathing  shallow. 

The  leukocytosis  is  never  a  significant  feature  of  these  cases.  It  may 
be  high  or  low,  but  often  the  patient  dies  with  a  white  count  which  has 
never  run  above  15,000. 

The  diagnosis  of  diffuse  peritonitis  is  usually  obvious,  and  is  founded 
upon  the  initial  severe  pain,  the  tenderness  gradually  extending,  the 
abdominal  distention,  effusion,  fever,  collapse,  vomiting,  and  constipa- 
tion. One  must  differentiate  it  from  sundry  other  diseases — acute 
enterocolitis,  in  which  the  pain  is  more  colicky  and  a  diarrhea  frequent; 
hysteric  peritonitis,  which  Osier  describes  as  deceiving  the  very  elect. 
It  must  be  very  rarely,  however,  that  this  cannot  be  distinguished  from 
an  infectious  peritonitis;  intestinal  obstruction,  in  which  the  prostration 
comes  on  more  slowly,  and  the  pain,  fever,  and  tenderness  are  less 
marked.  However,  intestinal  obstruction  is  a  frequent  cause  of  peri- 
tonitis; rupture  of  an  abdominal  aneurysm  or  embolism  of  the  superior 
mesenteric  artery;  acute  hemorrhagic  pancreatitis;  and  rupture  of  a  tubal 
pregnancy.  All  those  conditions  may  simulate  peritonitis,  and  all  may 
be  associated  with  it,  but  whatever  the  true  condition,  the  symptoms 
are  those  of  an  alarming  intra-abdominal  disease  demanding  immediate 


228  THE   ABDOMEN 

treatment  by  operation  if  the  patient's  life  is  to  be  saved  and  if  liis  con- 
dition permits. 

In  the  treatment  of  <UlTuse  ]xM-itonitis  one  cannot  (Hvide  th(!  dis- 
ease, chnically,  into  "  sei)tic  peritonitis"  and  "  suiJi)urative  peiitonitis," 
as  is  often  asserted.  Until  he  opens  the  abdomen  no  man  may  tell 
with  what  he  is  dealin<2;.  In  like  manner  the  diffuse  scsj^tic,  gangreno- 
purulcnt,  and  fibrinopurulent  forms  of  von  Mikulicz  do  not  show  definite 
clinical  pictures;  and  then,  different  forms  of  peritonitis  may  be  present 
at  the  same  moment  in  different  parts  of  the  same  belly.  Nor  does 
a  knowledge  of  the  etiology  help  us  in  a  given  case.  The  uterus  infected 
at  childbirth  may  cause,  through  lymphatic  connections,  an  acute,  over- 
whelming peritonitis,  involving  in  a  day  almost  the  whole  peritoneal 
cavity — a  lethal  toxemia ;  or  an  infection  from  the  same  source  may  be 
insidious,  taking  weeks  to  develop,  gradually  progressing,  marked  by 
extensive  matting  of  the  viscera,  and  with  numerous  230ckets  of  pus. 
Therefore,  the  surgeon  can  never  be  sure  as  to  the  form  of  peritonitis 
with  which  he  is  dealing  until  he  opens  the  abdomen;  and  even  then  he 
may  be  at  fault  until  numerous  cultures  are  taken  or  the  problem  is 
solved  postmortem.  You  shall  confidently  open  an  abdomen  which 
you  take  to  be  the  seat  of  a  localized  appendicitis,  when  you  will  find  a 
diffuse  peritonitis.  On  the  other  hand,  you  may  make  a  diagnosis  of 
diffuse  peritonitis,  and  then,  upon  operating,  find  a  localized  process 
only.     Tl^ese  are  exceptional  experiences,  of  course. 

Then  there  is  the  question  of  definition.  We  still  talk  erroneously 
about  ''  general  peritonitis,"  meaning  an  inflammation  involving  the 
whole  of  the  peritoneum.  Probably  such  a  condition  never  exists. 
Certainly  no  man  can  determine  it  by  looking  through  an  operation 
wound.  The  most  we  can  say  at  operation  is  that  a  peritonitis  is  ex- 
tensive and  is  advancing  without  the  establishment  of  barriers  of  ad- 
hesions. Nor,  upon  opening  the  belly,  can  we  always  foretell  the  out- 
come of  a  peritonitis,  the  extent  of  the  disease,  or  its  prospects  of  self- 
limitation.  It  is  not  surprising,  therefore,  that  men  do  not  always 
mean  the  same  thing  when  they  write  or  speak  of  diffuse  or  general 
peritonitis;  and  to  the  confusion  arising  from  such  misunderstandings 
is  due  much  divergence  of  opinion  and,  to  a  degree,  the  wide  variation  in 
statistics. 

In  this  chapter  I  mean  by  diffuse  peritonitis  an  infectious  inflam- 
mation, progressive,  without  definite  barriers  of  adhesions,  spreading 
rapidly  by  continuity  throughout  the  peritoneal  cavity. 

There  are  three  views  to  be  taken,  clinically,  of  any  case  of  diffuse 
peritonitis.  One  may  feel  that  it  is  not  of  a  virvdent  type;  that  it  is 
making  slow  progress,  and  that  the  patient  will  recover  under  non- 
operative  treatment.  Or  the  case  may  be  so  active  and  progressive 
that  one  may  believe  an  operation  to  offer  the  only  chance  of  cure.  Or 
the  disease  may  have  advanced  further,  and  the  patient  be  so  profoundly 
septic  that  it  is  obvious  he  would  die  at  once  if  submitted  to  operation. 

Surgeons  are  coming  to  find  cases  of  the  first  class — the  non-operative 
class — to  be  more  and  more  rare,  though  some  competent  internists 


ACUTE    TEUITONITIS  229 

still  cling  to  the  belief  that  iiuuiy  of  these  mild  cases  may  best  be  treated 
"  medically."  My  conviction  is  that  peritonitis  is  a  "  surgical  disease," 
just  as  cancer  is  a  surgical  disease.  Thirty  years  ago  and  more  the 
opium  and  rest  treatment  of  peritonitis  had  an  astonishing  vogue  under 
the  teaching  of  Alonzo  Clark,  of  New  York,  and  his  disciples.  That 
treatment  consists  in  giving  immense  doses  of  opium,  thus  locking  up  the 
bowels,  paralyzing  peristalsis,  and  promoting  rest  and  limitation  of  the 
disease.  A  somewhat  similar  course  is  still  advocated  by  some  physicians, 
but  they  limit  the  dosage  of  opium  to  that  which  will  suffice  for  the  relief 
of  pain,  and  they  give  it  in  the  form  of  morphin  hypodermically.  They 
attempt  to  relieve  the  intestinal  distention  by  giving  high  enemata  of 
salts,  glycerin,  or  turpentine;  they  nourish  the  patient  by  enemata  or 
by  small  quantities  of  liquids  by  the  mouth;  and  they  allay  thirst  by 
allowing  the  patient  to  suck  cracked  ice. 

I  have  given  the  foregoing  description  of  one  method  of  treating 
diffuse  peritonitis  because  it  is  bad  treatment,  often  followed.  If  you 
purpose  to  treat  the  patient  without  operation,  you  must  resort  to  no 
such  half -measures.  The  proper  non-operative  method  is  to  put  the 
intestines  at  rest  by  emptying  the  stomach  through  lavage,  and  then 
keeping  it  empty.  The  stomach-washing  may  be  repeated  if  that  organ 
fills  up  again  with  material  regurgitated  from  the  intestine.  After 
washing  out  the  stomach,  put  into  it  nothing  until  convalescence  is 
established — no  water,  no  food,  no  cracked  ice.  Give  morphin  for  pain 
if  there  is  pain.  Nourish  the  patient  b}^  nutrient  enemata,  in  four-ounce 
doses  every  four  hours.  Relieve  his  thirst  by  subpectoral  infusions 
of  normal  salt  solution,  by  intravenous  infusions,  or  by  rectal  enemata. 
Stimulate  him  with  strychnin.  Such  treatment,  heroically  followed, 
will  often  head  off  and  subdue  an  advancing  peritonitis.  Such,  essen- 
tially, is  the  treatment  sometimes  advocated  by  Ochsner. 

Most  surgeons,  however,  are  loath  to  adopt  these  measures  as  a  routine 
because  they  feel  that  the  fountain-head  of  the  trouble,  the  local  lesion, 
— perforated  appendix,  duodenum,  or  whatever  it  may  be, — is  thus  left 
to  keep  up  its  contribution  of  poison  to  the  peritoneum.  I  am  in  hearty 
sympathy  with  this  view.  I  believe  in  operating  to  remove  the  primary 
cause.  How  shall  we  operate?  There  again  we  are  upon  debated 
ground.  The  debate  is  so  recent  that  some  reference  to  the  practice  of 
sundry  operators  will  be  instructive.  There  are  those  who  wash  out  the 
abdomen  and  those  who  wipe  it  out;  those  who  eviscerate  the  patient,  and 
those  who  handle  his  entrails  as  little  as  possible;  those  who  drain  the 
abdomen,  and  those  who  sew  it  up;  those  who  insist  upon  a  particular 
position  of  the  patient  to  aid  drainage,  and  those  who  disregard  this 
factor;  those  who  feed  by  the  mouth,  and  those  who  feed  by  the  rectum; 
those  who  drain  the  distended  gut  hj  enterostoni)' ;  and  those  who  inject 
into  it  cathartics  and  food.  Some  of  these  practices  I  indorse;  others  I 
condemn.  I  have  seen  surgeons  discard  some  of  them  after  half-hearted 
and  incomplete  trials,  and  I  have  seen  failures  in  my  own  hands,  as  well 
as  in  the  hands  of  others,  because  we  did  not  grasp  the  significance  of 
conditions  or  the  proper  value  of  certain  factors  in  technic. 


230 


THE    ABDOMEN 


^  X6.Mi,n,fo>-J 


'0mst' 


Alonzo  Clark  and  Ochsner  are  correct,  of  course,  when  they  pro- 
claim that  the  intestines  must  be  put  at  rest ;  but  others  are  correct  when 
they  assert  that  we  must  oHminatc  the  primary  focus  of  disease.  More- 
over, we  must  in  some  fashion  ])rovide  for  the  escape  of  septic  material 
from  the  abdomen;  we  must  encourage  the 
secretory  organs — the  kidneys,  most  of  all — 
to  take  up  their  allotted  task ;  we  must  nourish 
the  organism;  we  must  quench  thirst;  we  must 
stimulate  the  flagging  circulation;  we  must  sub- 
due pain.  Every  one  of  these  details  is  im- 
portant. 

We  have  learned  from  the  researches  of 
Cannon  and  F.  T.  Murphy  that  certain  im- 
pressions will  check  intestinal  peristalsis,  while 
others  may  be  applied  without  that  effect  on 
the  bowel.  Those  investigators  put  to  them- 
selves the  question,  why  is  it  that  a  temporary 
intestinal  paralysis  follows  almost  every  ab- 
dominal section?  In  their  experiments  on  ani- 
mals they  opened  the  abdomen,  exposed  the 
viscera  to  the  air  for  a  time,  and  then  sewed  up 
the  abdomen.     Xo  intestinal  paralysis  resulted. 


-^^^^JBr^^-ffA^j  ■   '-" 


ft.r'hO-  Huui-t-.i        of. 


A 


I'lj:.  ]■_".». — Flushing  the  abdominal  cavity. 


In  like  manner,  after  filling  the  abdomen  with  salt  solution,  no  paralysis 
followed;  but  handling  the  bowel  caused  a  paralysis  of  peristalsis,  and 
the  more  and  the  rougher  the  handling,  the  longer  the  paralysis — for 
four,  six,  twelve,  and  even  twenty-four  hours. 

Now,  abundant  flushing  of  the  abdominal  cavity  in  case  of  diffuse 


ACUTE   PERITONITIS  231 

peritonitis  was  an  early  and  obvious  expedient  in  treatment  after  remov- 
ing the  source  of  infection — flushing  through  a  tube  passed  deeply  into  all 
parts  of  the  cavity,  using  warm  decinormal  salt  solution,  several  gallons, 
and  leaving  a  goodly  amount  in  the  cavity.  This  method  is  employed 
by  many  surgeons.  One  must  endeavor  not  to  disturb  and  bruise  the 
intestines,  and  should  work  through  a  single  opening  below  the  navel, 
when  possible.  Do  not  wipe  the  intestines;  by  so  doing  one  adds  to  the 
traumatism  and  increases  the  paralysis.  For  like  reason  do  not  eviscer- 
ate. Do  not  sew  up  the  abdomen:  drain  it.  Fowler's  position  assists 
drainage;  of  that  I  shall  speak  later.  Do  not  feed  by  the  mouth  until 
convalescence  is  established.  As  for  enterostomy — direct  drainage  of 
the  distended  gut  through  a  tube  low  in  the  ileum  or  in  the  cecum — that 
is  a  maneuver  of  questionable  expediency.  In  an  admirable  essay 
Greenough  ^  has  discussed  this  subject,  and  concludes  that  the  opera- 
tion has  a  place  in  cases  of  extremely  grave  peritonitis.  In  this  con- 
nection he  formulates  17  interesting  conclusions.  Of  these,  note  the 
following : 

"  The  obstruction  of  the  intestine  in  diffuse  peritonitis  is  the  result 
of  a  combination  of  causes. 

"  The  most  important  cause  is  suspension  or  paratysis  of  peris- 
talsis. 

"  Paralysis  of  peristalsis  is  due  to  inhibition,  to  toxic  paralysis,  and 
to  the  paralysis  of  distention. 

''  Mechanical  causes,  such  as  infiltration  of  the  bowel-wall  and  light 
adhesions,  in  certain  cases  contribute  to  this  paralysis. 

"  Enterostomy  is  indicated,  in  addition  to  other  operative  measures, 
in  graver  forms  of  diffuse  peritonitis. 

"  Its  greatest  advantage  is  the  drainage  of  the  gases  and  decompos- 
ing contents  of  the  bowel,  and  the  relief  of  paralysis  of  peristalsis." 

I  have  thus  presented  the  main  features  of  the  argument  of  those  who 
advocate  enterostomy,  because  the  importance  of  the  subject  warrants 
it,  and  because  the  matter  is  still  sub  judice,  but  the  figures  adduced 
and  my  own  experience  do  not  impress  me  with  the  value  of  this 
procedure. 

After  a  careful  studj-  of  many  papers,  much  discussion  wdth  winters, 
an  elaborate  comparison  of  statistics,  and  a  general  hospital  experience 
of  twenty-two  years,  I  have  come  to  definite  conclusions  regarding  the 
treatment  of  diffuse  peritonitis.  In  general  terms — every  patient  with 
diffuse  peritonitis  should  be  operated  upon  as  soon  as  seen  unless,  in 
the  judgment  of  an  experienced  surgeon,  he  is  nearl}-  moribund.  The 
operation  should  be  reduced  to  a  minimum  in  time  and  extent.  The 
viscera  should  not  be  handled  except  so  far  as  is  unavoidable  in  remov- 
ing the  primary  focus  of  disease.  Irrigation  should  be  practised  when 
the  abdominal  fluid  is  thick  or  contains  numerous  masses  of  fibrin  and 
detritus.  These  should  be  washed  out  thoroughly  with  several  gallons 
of  warm  decinormal  salt  solution.  In  the  absence  of  these  masses  and 
when  the  fluid  is  thin,  irrigation  is  needless.  Adequate  drainage  should 
1  R.  B.  Greenough,  Boston  Med.  and  Surg.  Jour.,  May  19,  1904. 


232 


THE    ABDOMEN 


be  provided,'  the  intestines  should  l)c  kcjjt  at  rest  after  the  operation, 
and  the  organism  should  be  sustained. 

To  accomplish  these  objects  I  have  followed  for  the  past  six  years 
the  methods  formulated  In-  J.  Jl  Murphy.-  For  these  methods  my  res- 
pect is  constantly  increasing,  and  1,  therefore,  advise  the  following  pro- 
cedures. 

Open  the  abdomen  as  low  as  possible,  through  a  short  incision,  three 
or  four  inches  long.  Seek  and  remove  the  primarv  disease.  By  the 
short  incision  shock  is  minimized,  as  the  intestines  are  but  little  exposed. 
They  should  not  be  allowed  to  escape;  from  the  abdomen. 

Do  not  irrigate  the  abdomen  except  under  such  circumstances  as  I 
have  described  on  p.  231.  Under  no  circumstances  attempt  to  wipe 
clean  the  peritoneum,  inasmuch  as  the  adherent  coagulated  lymph  acts 


Fig.  130. — The  iron  bed  in  position  on  the  .springs  of  a  ward  bed.     Draw-sheet  ar- 
ranged as  for  continuous  irrigation  (W.  D.  Gatcli). 


as  a  protective  and  its  removal  gives  an  opportunity  for  the  absorption 
of  fresh  toxins. 

Drain  through  the  operation  wound,  and  drain  the  pelvis  through  a 
stab-wound  above  the  pubes.  Van  Buren  Knott,  in  a  valuable  paper,^ 
advises  draining  the  pouch  of  Douglas  in  women  through  the  vagina — 
an  admirable  measure.  Employ  Fowler's  postural  method  to  assist 
drainage.  This  method,  described  by  George  Ryerson  Fowler,*  of 
Brooklyn,  in  1900,  is  an  advance  of  great  importance.^  We  have  seen 
that  the  peritoneum  in  the  region  of  the  diaphragm  is  most  rich  in  its 
lymphatic  connections,  while  the  pelvic  peritoneum  is  relatively  poor 

1  See  Robert  C.  Coffey,  Tlie  Principles  and  Mechanics  of  Abdominal  Drainage, 
Jour.  Amer.  Med.  A.ssoc.,' March  16,  1907. 

2  J.  B.  Murphy  in  the  Practical  Medicine  Series,  Surgery,  series  of  1903. 

3  Van  Buren  Knott,  Ann.  Surg.,  .Julv,  1905. 

*G.  R.  Fowler,  Medical  Record,  January  16  and  April  14,  1900. 
5  Russell  S.  Fowler,  New  York  State  Jour.  Med.,  October,  1907. 


ACUTE   PERITONITIS 


233 


in  such  lymphatics.  For  this  reason  peritonitis  in  the  upper  portion  of 
the  abdomen  is  more  fierce  in  its  coiu'se  and  more  immediately  over- 
whelming than  is  pelvic  peritonitis.  Our  endeavor  must,  therefore,  be 
to  drain  septic  products  away  from  the  upper  to  the  lower  portions  of  the 
abdomen,  and  we  know  that  the  trend  of  peritonitis  is  largely  dependent 
on  gravity.  We,  therefore,  employ  Fowler's  position,  which  consists  in 
sitting  the  patient  in  a  posture  as  nearly  upright  as  he  can  maintain 
without  distress  or  fatigue.  Then  the  fluids  gravitate  to  the  pelvis  and 
are  drained  away  by  tubes  and  wicks  placed  there  to  receive  them. 
The  pumping  action  of  the  diaphragm  also  forces  the  fluids  down. 
As  LeConte  ^  remarks:  ''  It  must  be  remembered  that  it  is  not  the  quan- 
tity of  fluid  present  which  is  harmful,  but  rather  the  extent  of  the  peri- 


Fig.  131. — Special  drainage-tubes  (Crandon  and  Scannell). 

toneal  surface  which  comes  in  contact  with  it,  so  that  a  quart  of  pus 
contained  in  a  round  cavity  would  be  less  dangerous  than  an  ounce  thinly 
coating  over  the  peritoneal  surface." 

I  use  large  rubber  drainage-tubes  of  the  split  pattern  suggested  to 
me  by  B.  G.  A.  Moynihan — one  tube  through  the  operation  wound  to 
the  initial  focus  of  disease,  one  through  the  suprapubic  opening  to  the 
bottom  of  the  pelvis,  and  one  in  the  vagina,  if  that  is  incised. 

The  wounds  are  covered  with  an  abundant  absorbent  dressing,  which 
must  be  changed  frequently,  as  it  quickly  becomes  soaked.  The  whole 
operation  should  take  a  short  time  in  most  cases,  and  the  amount  of 
anesthetic  used  should  be  small. 

1  R.  G.  LeConte,  Ann.  Surg.,  Februarj-,  1906. 


'234  THE    ABDOMEN 

I  do  not  approve  of  multiple  punctures  of  the  bowel;  as  for  a  single 
puncture,  that  accomplishes  nothing;  nor  do  I  approve  of  injecting 
saline  cathartics  into  the  bowel. 

The  after-care  of  the  patient  is  an  extremely  important  part  of  the 
treatment.  Our  purpose  is  to  leave  the  l)owels  absolutely  at  rest  until 
nature  has  had  a  chance  to  reassert  herself.  So  we  give  nothing  by  the 
mouth,  but  we  introduce  abundance  of  water  into  the  rectum  by  the 
well-known  "  seeping"  method  employed  by  Murphy.*  For  this  pur- 
pose insert  within  the  sj^hincter  a  large-sized  nozzle  with  several  open- 
ings, fed  through  a  long  tube  from  a  reservoir  elevated  but  a  few  inches 
above  the  level  of  the  anus.  A  gentle  trickle  of  salt  solution  is  thus  led 
into  the  rectum,  and  led  so  slowly  that  it  is  absorbed  as  fast  as  it  flows 
in.  Many  quarts  are  thus  taken  up  in  the  course  of  twenty-four  hours, 
the  stream  being  intermitted  from  time  to  time  if  it  seems  best.  Thus 
two  important  objects  are  attained:  first,  the  septic  stream  from  the 
peritoneum  into  the  lymph-channels  is  reversed;  fluid  pours  into  the 
peritoneum  instead  of  away  from  it ;  the  patient's  upright  position  causes 
this  fluid  to  gravitate  to  the  pelvis,  and  an  abundant  discharge  escapes 
and  soaks  the  dressings.  In  the  second  place,  the  increased  amount  of 
water  in  the  circulation  stimulates  the  heart  and  kidneys;  it  allays 
thirst,  and  supplies  nutriment.  Moreover,  if  necessaiy,  liquid  absorbable 
food  may  be  mixed  with  the  solution  injected.  The  output  of  urine 
increases  surprisingly,  man}'  pints  being  passed  in  twenty-four  hours. 
It  is  interesting  to  observe  in  this  connection  that  fluid  thus  indirectly 
introduced  into  the  peritoneal  cavity  maintains  continuous^,  effectively, 
and  without  irritation  the  action  which  we  crudely  attempted  to  pro- 
duce when  we  pumped  a  great  quantity  of  water  into  the  belly  at  the 
time  of  the  operation.     Seeping  supplants  sluicing. 

Whereas  we  expected  a  death-rate  of  from  70  to  SO  per  cent,  from 
acute  diffuse  peritonitis  under  previous  forms  of  treatment,  it  seems 
reasonable  to  expect,  judging  from  the  relatively  few  cases  as  yet  avail- 
able for  statistics,  that  the  mortality  ma}-  be  kept  below  30  per  cent, 
if  we  follow  the  treatment  I  have  just  described. 

CHRONIC  PERITONITIS 

Chronic  peritonitis  is  an  unsatisfactory  term,  for  it  is  often  hard  to 
determine  where  acute  peritonitis  ends  and  chronic  peritonitis  begins. 
We  recognize  two  forms:  exudative  chronic  peritonitis  and  adhesive 
chronic  peritonitis;  while  it  would  be  proper  enough  to  include  tubercu- 
lous and  malignant  peritonitis  under  the  caption  chronic. 

Exudative  peritonitis  is  so  closely  allied  clinically  to  tuberculous 
peritonitis  that  it  is  extremely  difficult  to  distinguish  the  two.  The  con- 
dition is  rather  rare,  and  is  characterized  by  a  general  and  abundant 
fluid  exudate.  We  do  not  know  what  causes  exudative  pei-itonitis, 
though  it  has  been  ascribed  to  catching  cold  and  to  traumatism.  The 
fact  that  it  is  most  common  in  young  women  and  that  it  frequently  starts 

1  J.  B.  Murphy,  Proctoclysis  in  the  Treatment  of  Peritonitis,  Jour.  Amer.  Med. 
Assoc,  April  17,  1909. 


CHRONIC    PERITONITIS  235 

in  the  pelvis  suggests  that  its  origin  lies  in  the  Fallopian  tubes.  Indeed, 
it  has  been  observed  to  occur  for  the  first  time  at  the  beginning  of  men- 
strual life.  It  comes  on  gradually  with  fluid  slowly  collecting  in  the 
abdomen,  with  or  without  pain.  If  the  fluid  accumulates  in  great 
amounts,  it  may  interfere  with  the  functions  of  the  abdominal  organs, 
especially  the  intestines.  Sometimes  small  nodular  masses  like  pebbles 
may  be  felt  in  the  umbilical  region.  There  is  fever  often.  The  general 
health  is  affected,  and  the  patient  becomes  pale,  weak,  and  emaciated. 
Not  infrequently  there  is  an  associated  pleurisy. 

It  is  almost  impossible,  by  an  ordinary  examination,  to  distinguish 
such  a  case  from  tuberculous  peritonitis,  but  a  proper  conclusion  may 
be  reached  through  the  tuberculin  test,  or  by  inoculating  animals  with 
the  aspirated  fluid.  One  must  distinguish  the  disease  from  the  various 
forms  of  ascites  also.  A  majority  of  the  patients  recover  under  the  use 
of  internal  remedies,  mercurial  inunctions,  and  hydrotherapy. 

Treatment  by  operation  is  indicated  in  obstinate  cases,  especially  if 
one  cannot  exclude  tuberculosis.  Sometimes  the  exudate  will  disappear 
after  repeated  tappings.  Sometimes  an  abdominal  section,  with  remo- 
val of  the  fluid  and  irrigation,  cures  promptly. 

Chronic  adhesive  sclerosing  peritonitis  or  plastic  peritoneal 
sclerosis  is  an  interesting  disease,  and  not  an  uncommon  one.  Writers 
are  wont  to  complain  that  text-books  give  scant  attention  to  diseases 
in  which  they  themselves  happen  to  be  especially  interested,  and  I  find 
Wetherill  ^  remarking  of  sclerosing  peritonitis  that  it  "  is  treated  but 
slightty  and  irregularly  in  American  text-books."  This  disease  occurs  at 
one  or  at  several  points  in  the  peritoneal  cavity,  but  favors  especialty 
the  region  of  the  Fallopian  tubes,  the  gall-bladder,  the  flexures  of  the 
colon,  the  posterior  part  of  the  peritoneum,  the  root  of  the  mesentery, 
the  mesosigmoid,  and  the  omentum.  There  result  a  thickening  and  a 
shrinking  of  the  peritoneum.  The  disease  may  also  be  a  sequel  of  acute 
infection  of  the  intestine  and  of  traumatism.  Moreover,  it  may  start 
in  a  chronic  form,  and  without  an  acute  stage  may  develop  far  without 
the  patient  being  aware  of  any  cause  for  its  onset.  Histologically,  one 
observes  extensive  subperitoneal  scleroses.     There  is  no  exudate. 

The  symptoms  are  obstinate  constipation,  leading  to  obstruction 
even,  with  nausea  and  vomiting,  pain,  and  tenderness.  In  the  milder 
cases  there  are  constant  abdominal  uneasiness,  dyspepsia,  malnutrition, 
and  occasional  attacks  of  colicky  pain  several  hours  after  eating,  since 
the  dense  adhesions  interfere  with  the  normal  flow  of  the  intestinal 
stream. 

The  surgical  treatment  of  this  disease  is  not  always  satisfactory, 
though  it  is  the  only  treatment  which  gives  any  prospect  of  permanent 
rehef.  The  operation  consists  in  opening  the  abdomen  and  dividing 
the  bands  of  adhesions  which  are  found.  It  may  be  necessary  also  to 
remove  organs  which  appear  to  be  the  source  of  disease — such  organs  as 
the  appendix,  the  gall-bladder,  and  the  Fallopian  tubes.  Sometimes 
the  patient  is  cured  permanently  by  the  operation;  sometimes  the  dis- 
1  Jour.  Amer.  Med.  Assoc,  March  5,  1904. 


236  THE    ABDOMEN 

ease  recurs  and  may  extend  slowly  until  it  involves  the  greater  part 
of  the  peritoneum.  Various  methods  have  been  devised  to  prevent  the 
reformation  of  adhesions,  such  as  the  introduction  of  Cargile  membrane 
between  wounded  surfaces,  the  copious  dusting  with  aristol,  and  the  in- 
terposition of  omental  grafts.  These  substances  are  often  useful,  and 
since  one  can  never  foresee  the  outcome  of  the  operation,  their  employ- 
ment is  justifiable. 

On  the  whole,  we  may  not  regard  the  outlook  as  favorable,  though  I 
cannot  agree  with  Beck  '  in  his  statement  that  "  my  experience  in  cases 
of  chronic,  progressive,  adhesion-forming  peritonitis,  as  it  is  observed 
idiopathically,  as  well  as  after  appendicitis,  is  absolutely  bad.  The 
nature  of  this  peculiar  condition,  characterized  by  a  multitude  of  cob- 
web-shaped bands,  is  not  yet  sufficiently  elucidated." 

Tuberculous  peritonitis  is  one  of  the  puzzles  of  surgical  practice. 
It  is  insidious;  it  is  confusing;  it  ma}^  simulate  a  great  number  of  diseases. 
Whenever  you  see  a  patient  with  somewhat  distended  abdomen,  with 
indefinite  dj^speptic  symptoms,  and  with  an  uncertain  history  of  ab- 
dominal pain,  you  must  think  of  tuberculous  peritonitis.  Appendicitis 
and  tuberculous  peritonitis  are  so  common  and  so  elusive  often  that  they 
should  alw^ays  be  in  the  mind  of  the  surgeon  when  he  examines  an  ab- 
domen, though  one  may  choose  to  relegate  appendicitis  to  the  group  of 
acute  diseases,  and  tuberculous  peritonitis  to  the  group  of  chronic 
diseases. 

One  finds  three  distinct  forms  of  tuberculous  peritonitis,  which  have 
been  classified  as — (1)  The  ascitic  form;  (2)  the  fibro-adherent ;  (3)  the 
ulcerative.  Hawkins,  in  a  much-quoted  article,  describes  four  clinical 
varieties:  the  latent;  the  severe,  with  ascites  and  a  spontaneous  tendency 
to  remissions  or  incapsulation;  a  cheesy,  purulent  form;  a  fibrous- 
adhesive  form.  Such  classifications  are  all  veiy  well,  but,  unfortunately 
for  the  clinician,  these  forms  are  not  always  clearly  marked,  w'hile  more 
than  one  may  be  present  in  the  same  individual. 

Tuberculosis  of  the  peritoneum  rarely  is  primary — a  considerable 
majority  of  the  cases  are  secondary  to  tuberculosis  of  the  lungs,  or  the 
primary  focus  may  be  in  the  Fallopian  tubes,  the  intestines,  the  appen- 
dix, and  the  abdominal  lymph-nodes;  the  infection  maybe  brought  by 
the  blood-stream  to  the  peritoneum  from  a  tuberculous  center  in  some 
remote  part  of  the  body.  We  need  not  consider  here  the  rather  uncom- 
mon, acute,  miliary  tuberculosis,  which  is  but  part  of  a  general  tubercu- 
losis.^    We  are  dealing  now-  with  a  chronic  process. 

Tubercles  may  be  found  scattered  or  thickly  set  over  the  peritoneum, 
associated  with  an  exudate  free  in  the  peritoneal  cavity,  or  one  sees  nod- 
ular masses  undergoing  caseous  or  ulcerative  change.s— the  nuclei  of 
further  trouble.  There  may  be  extensive  matting  of  viscera,  with  in- 
filtration of  the  organs,  producing  a  friable  condition  of  tissue.  There 
may  be  extensive  involvement,  ulceration,  and  destruction  of  organs. 
The  omentum  and  the  intestines  are  the  parts  most  frequently  affected. 

1  Carl  Beck,  Amer.  Med.,  April  1,  1905. 

2  Brunn,  Cent.  f.  allg.  Path.  u.  path.  Anat.,  1902. 


CHRONIC   PERITONITIS  237 

The  symptoms  of  tuberculous  pciitoiiitis  are  extremely  variable,  but, 
as  a  rule,  one  finds  pain  coming  and  going,  fever,  emaciation,  anemia, 
anorexia.  The  bell}-  i.s  ballooned;  there  is  often  ascites,  with  diarrhea 
alternating  with  constipation.  Sometimes  there  appears  an  inflamed 
zone  about  the  navel;  rarely  there  are  sinuses  dischaiging  pus  or  feces. 
Palpation  is  unsatisfactory;  at  different  times  different  impressions  are 
conveyed  to  the  hand;  lumps  appear  and  disappear;  fluid  may  be  found 
free,  or  it  may  be  locked  up  in  pockets.  One  discovers  a  condition  of 
tension  or  hardness  in  the  abdominal  wall — a  peculiar  elastic  resistance. 
Thomayer's  sign  is  often  valuable :  in  the  shortening  of  the  mesentery 
resulting  from  infiltration  the  entire  mass  of  intestinal  coils  may  be 
drawn  upward  and  backward  to  the  right,  while  fluid  will  be  found  ac- 
cumulated below  and  to  the  left.  Sometimes  the  fluid  of  tuberculous 
peritonitis  accumulates  in  great  amounts.  The  fig-ures  of  the  Massachu- 
setts General  Hospital,  gathered  by  Shattuck  and  W.  H.  Smith,  show 
that  the  disease  is  most  common  between  the  ages  of  twenty  and  thirty, 
while  liability  to  it  cHminishes  as  we  approach  the  extremes  of  birth  and 
old  age.     It  is  rare  in  infancy;  rarer  still  after  sixty. 

In  making  the  diagnosis  one  considers  the  common  symptoms :  ab- 
dominal  pain;  the  frequent  diarrhea;  the  nausea  and  vomiting,\]ie  fluid 
in  the  abdomen,  the  masses  to  be  felt.  Leukocytosis  is  infrequent;  the 
temperature  is  usually  slightly  elevated,  especially  in  the  e^-ening.  The 
tuberculin  test  is  generally  positive,  but  a  much  more  satisfactory  test 
is  the  injection  of  the  abdominal  fluid  into  guinea-pigs. 

Twenty-five  years  ago  we  were  taught  that  tuberculous  peritonitis 
is  an  invariably  fatal  disease.  To-day  we  have  abundant  proof  that 
it  is  not  invariably  fatal,  and  that  patients  often  recover,  under  all 
varieties  of  treatment  and  under  varying  conditions  of  hygiene.  A 
number  of  statistics  show  we  are  safe  in  concluding  that,  under  proper 
care,  30  to  40  per  cent,  of  the  patients  will  recover. 

In  chscussing  the  treatment  of  tuberculous  peritonitis  writers  have 
been  wont  to  quote  the  case  of  Spencer  Wells,  who  operated  upon  a 
young  woman  for  an  ovarian  cyst  some  forty  years  ago,  and  found  a 
tuberculous  peritonitis.  He  sewed  up  the  belly  and  the  patient  got  well. 
So,  men  have  pointed  to  this  case  as  a  post  hoc,  propter  hoc.  In  large 
measure,  therefore,  the  discussion  of  the  treatment  of  tuberculous  peri- 
tonitis has  centered  around  the  question,  to  operate  or  not  to  operate. 
Tntil  recently  the  discussion  was  largely  futile,  because  onh^  recently 
have  we  come  to  see  clearly  that  operation  is  of  benefit  to  those  patients 
mostly  from  whom  the  focus  of  disease  can  be  removed.  Numerous 
cases  are  reported  in  which  the  abdomen  was  opened,  or  was  opened 
and  drained,  or  was  irrigated  or  variously  treated.  In  any  case  the 
operation  was  extremely  simple,  and  many  of  the  patients  got  well; 
so  clinicians  have  been  debating  in  what  way  the  operation  benefits. 
There  have  been  numerous  attempts  at  an  explanation — most  of  them 
more  or  less  meaningless.  Eichberg  ^  sums  up  the  debate  as  to  why  lap- 
arotomy cures  tuberculous  peritonitis  by  saying  "  because  it  does  not." 
^  Joseph  E.  Eichberg,  Jour.  Amer.  Med.  Assoc,  October  3,  1903. 


238  THE    ABDOMEN 

Such  a  statcinont  is  too  sweeping.  It  is  logical  to  doubt  the  beneficial 
effect  of  laparotomy  when  the  abdomen  has  been  opened,  washed  out, 
and  sewed  up  without  the  removal  of  a  focus,  but  with  the  subsequent 
recovery  of  the  patient.  In  such  a  case  one  may  reasonably  claim  that 
the  patient  would  have  recovered  under  medical  treatment.  On  the 
other  hand,  I  agree  with  J.  B.  Murphy  when  he  says:  "  The  benefit  from 
an  operation  for  tuberculous  peritonitis  will  depend  upon— (a)  The 
removal  of  the  source  of  continued  supph^,  which  can  almost  uniformly 
(?)  be  accomplished;  (b)  the  degree  of  adhesions  in  the  peritoneum;  (c) 
the  reparative  stimulation  produced  in  the  peritoneum  by  the  opera- 
tion." ' 

Since  the  Fallopian  tubes  are  a  common  source  of  infection,  it  is  ob- 
vious that  removal  of  the  tubes,  in  the  case  of  young  women  suffering 
from  tuberculous  peritonitis,  will  effect  a  cure.  On  the  other  hand,  men 
are  not  such  proper  subjects  for  operation,  and  are  wont  more  than 
women  to  recover  under  medical  treatment.  Further,  those  cases  with 
few  adhesions  and  abundant  fluid  in  the  cavity  will  often  recover 
rapidly  after  the  operation  of  opening  and  flushing.-  Those  cases  in 
which  the  cavity  is  obliterated  by  adhesions  are  not  improved  by  any 
operation.  Finally,  since  we  know  that  many  cases  of  tuberculous 
peritonitis  are  due  to  extension  from  disease  of  the  chest,  and  since  we 
are  assured  that  pulmonary  tuberculosis  does  not  contravene  the  pos- 
sibility of  a  cure  of  peritoneal  tuberculosis,  we  are  justified  in  asserting 
that  a  large  number  of  cases  of  peritoneal  tuberculosis  secondary  to 
pulmonary  tuberculosis  will  recover  without  operation.  If  no  opera- 
tion is  done,  do  not  keep  the  patient  in  the  hospital.  Insist  upon  a  con- 
tinuous out-of-door  life,  with  an  abundance  of  nutritious  food  and,  if 
possible,  eliminate  mental  strain  and  anxiety. 

Malignant  peritonitis — the  involvement  of  the  peritoneum  in 
cancer  or  sarcoma — need  not  detain  us  further  than  to  note  that  primary 
malignant  disease  of  the  peritoneum  is  rare,  but  that  in  advanced  malig- 
nant disease  of  the  ovary,  intestines,  and  other  abdominal  organs,  the 
peritoneum  ma}'  become  extensively  involved  in  metastatic  growths. 
The  omentum  especially  may  be  found  to  be  the  seat  of  secondary 
growths.  In  such  cases  the  abdomen  usually  contains  an  abundant, 
thin  hemorrhagic  fluid,  which  may  be  withdra-uTi  by  aspiration  if  it  is 
so  great  as  seriously  to  interfere  with  the  functions  of  organs.  Any 
further  operation  is  useless,  as  the  condition  is  fatal  and  operation  always 
hastens  death.     Palliative  measures  alone  are  of  service. 

THE  RETROPERITONEAL  SPACE 

The  retroperitoneal  space  is  not  a  space.  It  is  all  that  indefinite, 
ill-defined  area  which  lies  immediately  outside  of  the  peritoneum.  Now, 
it  is  the  well-defined  plane  beneath  the  abdominal  and  back  muscles; 

1  J.  B.  Murphy,  Practical  Medicine  Series,  General  Surgerj-.  series  1905,  p.  288. 

2  The  student  should  consult  A.  Dijll's  paper  in  rcfjard  to  vioform  irrigations, 
Arch.  Internal,  de  Chir.,  1907,  No.  5:  quoted  also  in  the  Practical  Medicine  Series, 
vol.  ii,  General  Surgery,  for  1908,  p.  327. 


THE   RETROPERITONEAL   SPACE 


239 


again,  it  is  that  hypothetic  area  which  lies  in  and  follows  the  folds  of 
the  broad  ligaments,  omentum,  mesentery,  and  other  such  structures. 
It  is  made  up  everywhere  of  more  or  less  loose  connective  tissue,  rich 
in  lymph-channels,  and  with  an  abundant  blood-supply.  Its  intimate 
relations  with  the  peritoneum  and  abdominal  cavity  make  it  interest- 
ing, and  magnify  an  importance  which  would  be  otherwise  slight. 
Serious   inflammations  occur  in  the  retroperitoneal  space — inflamma- 


Fig.  132. — Retroperitoneal  lymph-nodes  (redrawn  from  Sobotta). 

tions  which  may  involve  the  neighboring  peritoneum.  Sometimes 
tumors  arise  there,  and  in  the  course  of  their  development  incommode 
abdominal  organs  and  simulate  tumors  of  the  abdominal  viscera. 

Tuberculosis  of  the  retroperitoneal  lymph-nodes  and  the  in- 
volvement of  those  nodes  in  Hodgkin's  disease,  cancer,  and  like  affections 
form  an  interesting  chapter,  becoming  more  apparent  with  our  increas- 
ing knowledge. 


240  THE   ABDOMEN 

The  nodes  of  the  retroperitoneal  .space  foini  two  princi})ai  and  equally 
important  groups — the  mesenteric  group  and  the  lumbar  group.  The 
mesenteric  gi'oup  of  nodes  lies  in  the  mesentery  of  the  intestines  and  is 
closely  associated  with  the  mesenteric  vessels.  These  nodes  form  the 
filter  for  the  intestinal  lymphatics.  The  lumbar  group  of  nodes  lies  close 
to  the  lateral  and  anterior  portions  of  the  vertebral  column,  from  the 
origin  of  the  superior  mesenteric  arteiy  down  to  and  below  the  bifur- 
cation of  the  aorta;  the}'  have  some  slight  connection  with  the  alimen- 
tary tract  through  the  lymphatics  of  the  stomach  and  i-ectum,  but  their 
important  connection  is  with  the  lymph-channels  from  the  legs,  the 
pelvis,  and  the  l-ower  parts  of  the  trunk.  The}'  are  connected  with  the 
thoracic  nodes  also. 

Both  sets  of  nodes  are  often  invoh'ed  in  disease,  especially  in  tuber- 
culosis. There  is  the  general  miliary  tuberculosis,  which  need  not 
concern  us  as  surgeons,  as  well  as  chronic  tuberculosis,  with  a  general 
involvement  throughout  the  body.  More  rarely,  the  retroperitoneal 
nodes  alone  may  he  tuberculous,  and  this  is  especially  true  in  the  case  of 
children.^ 

There  are  three  important  sources  of  infection  :  direct  extension  from 
adjacent  tissues;  infection  through  the  blood-stream,  and  infection 
through  the  lymphatics.  In  children,  the  mesenteric  group  infected 
from  the  intestines  [typhoid,  etc.],  is  most  commonly  involved;  in  adults, 
the  lumbar  group.  The  course  of  the  disease  is  slow,  but  while  present, 
a  tuberculous  peritoneal  node  is  always  a  serious  menace  to  health  and 
life.  Nodes  become  enlarged  and  break  down,  forming  masses  of  tuber- 
culous detritus  or  calcification.  They  may  become  encysted  and  ^^•alled 
off  and  cease  to  cause  trouble.  More  frequently,  however,  the  disease 
of  the  lymph-nodes  spreads,  involving  node  after  node,  until  the  abdom- 
inal cavity  seems  to  be  filled  with  masses  crowding  the  viscera,  and 
associated  with  numerous  adhesions.  The  disease  may  invade  the  peri- 
toneal cavity  and  give  rise  to  tuberculous  peritonitis. 

The  symptoms  are  usually  gradual,  for  a  long  time  earh-  in  the  disease 
there  are  occasional  dull  pains  associated  with  deep  localized  tenderness. 
Later  the  abdomen  may  become  distended  and  ascites  or  jaundice  even 
may  develop.  At  the  same  time  there  are  cachexia,  intestinal  disturb- 
ance and  chronic  intestinal  obstruction,  with  large,  irregular,  easily 
palpable  masses  within  the  abdomen.  This  is  the  condition  which  was 
formerly  called  tabes  mesenterica.  The  patient  dies  fi'om  inanition  and 
toxemia. 

The  diagnosis  is  by  no  means  easy  always.  One  must  distinguish 
the  disease  from  malignant  neoplasms,  vertebral  tuberculosis,  abdominal 
aneurysm,  osteomyelitis,  osteo-arthritis,  infectious  arthritis,  and,  as 
Painter  and  Ewing  point  out.  from  spinal  rigidity  due  to  inti'a-abdominal 
inflammatory  disease.  A  common  error  is  to  mistake  inflammation  of 
the  retroperitoneal  lymph-nodes  for  appendicitis.  One  should  never 
mistake  inflammation  of  these  nodes  for  acute  appendicitis,  but  the 

1  P.  F.  Morf,  New  York  Med.  Jour.,  vol.  Ixxviii,  p.  410:  C.  F.  Painter  and  W.  G. 
Ewing,  Amer.  Med.,  September  24,  1904:  T.  M.  Rotch,  Pediatrics,  pp.  392,  843,  etc. 


THE   RETROPERITONEAL    SPACE  241 

adenitis  does  closely  resemble  chronic  appendicitis,  and  I  have  several 
times  seen  the  abdomen  ojx-ned  under  this  misapprehension. 

The  ircatvicnt  is  sometimes  operative,  but  more  often  general  hygienic 
measures  suffice — the  course  familiar  to  us  in  the  treatment  of  all 
forms  of  tuberculosis:  an  open-air  life,  with  careful  dieting  and  absolute 
rest.  Sometimes,  in  addition  to  this,  one  may  greatly  help  the  patient 
by  applying  mechanical  supports,  such  as  the  leather  or  plaster  jacket 
which  holds  the  body  rigid,  promotes  comfort,  and  favors  absorption. 
Opei'ations  are  seldom  useful,  and  one  does  them  ordinal  ily  only  to 
relieve  special  symptoms,  such  as  obstruction  or  other  forms  of  general 
peritoneal  involvement.  Especially  it  may  be  necessary  to  remove  large 
masses  developing  in  and  destroying  the  omentum  or  causing  extensive 
omental  adhesions.  In  these  cases  one  must  always  drain  the  field  of 
operation.  The  lumbar  glands  are  the  more  frequent  subjects  of  opera- 
tion. On  account  of  their  nearness  to  the  spinal  column,  their  disease 
may  simulate  spinal  disease — indeed,  they  may  extend  to  and  involve 
the  spinal  column.  In  any  case  they  may  give  rise  to  extensive  cold 
abscess,  pointing  in  the  lumbar  region  or  below  Poupart's  ligament. 
If  such  an  abscess  is  opened,  its  course  will  prove  more  rapid  and  its 
healing  will  be  sooner  and  more  final  than  is  the  case  with  the  cold  ab- 
scess of  spinal  caries. 

On  the  whole,  the  outlook  is  not  positively  bad  in  case  of  tuberculosis 
of  the  retroperitoneal  nodes.  A  great  many  patients  recover  permanently 
from  the  disease,  especially  if  they  have  the  benefit  of  rigorous  out-of- 
doors  treatment. 

Tumors  of  the  retroperitoneal  space  are  not  infrequent.  Malig- 
nant tumors  rarely  are  primary  there,  while  malignant  metastases  can 
be  treated  on  general  palliative  principles  only. 

.  On  the  other  hand,  benign  tumors  are  often  removed  from  this  region 
and  offer  brilliant  opportunities  for  radical  surgery.  The  commonest 
tumors  of  this  class  are  lipoma,  fibroma,  myxoma,  and  similar  growths 
from  the  subserous  tissue.  They  may  arise  from  behind  the  solid  viscera 
in  the  loins,  or  within  the  mesentery  or  omentum,  and  may  attain  great 
size.  I  saw  recently  the  fragments  of  a  large  fibrolipoma  removed  by 
Edward  Reynolds.  The  total  mass,  as  it  lay  in  a  dish,  appeared  to  be 
as  great  as  a  seven-pound  baby. 

These  tumors  are  found  in  persons  of  all  ages,  and  may  cause  serious 
symptoms  through  pressure  on  the  abdominal  organs^dyspepsia,  mal- 
nutrition, extensive  wasting,  pain,  and  marked  abdominal  deformity. 
Rarely  there  may  be  obstruction.  The  only  method  of  treatment  is 
radical  excision;  and  since  the  diagnosis  is  necessarily  obscure,  the  sur- 
geon will  generally  open  the  abdominal  cavity  and  remove  the  growth 
through  the  peritoneum.  Often  one  must  dig  it  out  piecemeal.  If  the 
intestinal  tumor  involve  the  mesentery,  one  must  be  careful  not  to 
damage  the  intestinal  blood-supply.  Tumors  of  the  omentum  may  be 
removed  intact,  with  the  omentum  itself. 

Retroperitoneal  cysts  are  about  as  common  as  the  solid  tumors. 
The  rare  echinococcus  cyst  is  secondary,  and  is  found  within  the  peri- 

16 


242  THE   ABDOMEN 

toneal  cavity  proper,  its  favorite  seat  being  the  omentum.  We  occasion- 
ally find  primary  cysts,  especially  in  the  mesentery.  These  primary 
cysts  are  classed  by  Hahn  as  serous  cysts,  chyle  cysts,  and  blood  cysts. 
They  are  felt  as  rounded,  tense  movable  tumors  in  the  region  of  the 
navel.  They  may  grow  very  large,  reach  the  pelvis,  and  become  at- 
tached to  the  uterus  and  other  organs.  The  intestines  lie  in  front  of 
these  cysts. 

The  symptoms  of  retroperitoneal  cysts  are  not  noticeable  until  a 
considerable  tumor  has  formed,  when  the  patient  will  often  suffer 
grievously  from  intense  abdominal  pain,  dyspepsia,  constipation,  and 
obstruction  even. 

A  rare  form  of  cyst  is  the  epithelial  variety,  developing  in  the 
mesentery,  from  the  remains  of  the  omphalomesenteric  duct. 

Remains  of  the  Wolffian  and  Miillerian  ducts  may  develop  into  cysts,* 
and  may  possibly  be  removed  through  a  lumbar  incision,  without  an 
opening  through  the  peritoneum. 

The  treatment  of  the  more  common  cysts  consists  in  opening  and 
evacuating  them,  and  removing  as  much  as  possible  of  the  cyst-wall, 
without  damage  to  vessels;  then  stitching  the  remains  of  the  cyst-wall  to 
the  abdominal  wound  and  packing  the  cavity.  Perfect  healing  follows. 
An  epithelial  cyst  must  be  removed  entire,  otherwise  a  fistula  will  per- 
sist. An  echinococcus  cyst  cannot  be  removed,  but  must  be  opened 
and  drained. 

Teratoma  of  the  peritoneum  is  a  rare  condition,  and  the  growths 
are  classed  by  Lexer  as  simple  and  complex  dermoids,  fetal  inclusions, 
and  teratoid  mucous  tumors.  Simple  dermoids  are  found  in  the  mesen- 
tery or  omentum,  or  in  the  loin  behind  the  peiitoneum.  Complex  der- 
moids spring  from  the  ovaries  or  misplaced  testicles  and  are  found  in 
the  pelvis.  Fetal  inclusions  lie  between  the  layers  of  the  transverse 
mesocolon  or  the  omental  bursae.  Teratoid  mucous  tumors  are  either 
solid  or  polycystic,  and  contain  tissue  from  all  three  embryonic  layers. 
These  curious  growths  generally  may  be  easily  removed  through  abdom- 
inal section. 

You  will  see  from  the  rough  sketch  I  have  given  in  this  chapter  how 
numerous,  complicating,  elusive,  and  confusing  are  many  of  the  condi- 
tions of  disease  originating  in  the  peritoneum  itself  or  beneath  it.  Nearly 
all  these  diseases  have  intimate  relations  with  functional  derangements  of 
the  abdominal  organs,  so  that  it  is  necessary  for  the  surgeon,  when  con- 
fronted with  abdominal  disease,  to  bear  in  mind  the  possibilitj'  of  the 
peritoneal  or  extraperitoneal  origin  of  the  sj-mptoms  which  he  studies. 

1  See  also  F.  B.  Douglas,  Retroperitoneal  Cysts,  Jour.  Amer.  Med.  Assoc,  Decem- 
ber 22,  1906. 


CHAPTER  IX 

PTOSIS  OF   THE   ABDOMINAL    ORGANS— THE    ABDOM- 
INAL WALL 

In  this  chapter  I  shall  treat  two  subjects  of  widely  different  moment 
—abdominal  ptosis,^  a  common  condition,  which  may  complicate  and 
exaggerate  other  abdominal  diseases;  and  diseases  and  injuries  of  the 
abdominal  wall,  common  enough  conditions,  but  of  relatively  minor 
concern. 

ABDOMINAL  PTOSIS 

Abdominal  ptosis  is  a  subject  of  great  importance.  I  shall  not  at- 
tempt a  discussion  of  all  its  phases,  but  I  shall  point  out  briefly  what 
clinicians  may  do  to  relieve  the  symptoms  and  the  condition  ptosis  itself. 
Incidentally,  too,  I  must  say  a  word  on  the  general  subject  of  the  etiology 
of  ptosis,  as  there  is  a  good  deal  of  misunderstanding  of  that  matter,  so 
various  are  the  views  of  sundry  writers. 

Virchow  long  ago  recognized  visceral  ptosis,  and  movable  kidneys 
have  been  observed  for  many  years.  In  1881  Landau  wrote  a  mono- 
graph calling  attention  to  the  importance  of  movable  kidney  in  women. 
Glenard,  however,  in  1885  was  the  first  to  show  clearly  and  distinctly 
that  by  ptosis  of  the  abdominal  organs  one  may  explain  on  anatomic 
grounds  a  group  of  clinical  symptoms  hitherto  regarded  as  purely  func- 
tional. Glenard  maintained  that  sufferers  from  these  functional  dis- 
orders are  cured  of  their  dyspepsias,  backaches,  and  neurasthenias 
through  relief  to  the  ptoses  found  in  their  cases.  He  gave  the  name 
"  enteroptosis "  to  the  most  common  assemblage  of  derangements 
which  he  w^as  accustomed  to  find;  namely,  to  ptosis  of  the  intestines 
and  stomach  combined  with  a  prolapsed  right  kidney.  This  combina- 
tion of  lesions  has  been  called  Glenard's  disease.  The  term  "  splanch- 
noptosis" is  applied  to  prolapse  of  all  the  abdominal  viscera — a  very 
rare  condition.  Some  German  writers  and  others  recently  have  used 
the  term  "  splanchnoptosis"  in  place  of  the  older  and  more  common 
term,  enteroptosis.  The  displacement  of  single  organs  is  designated  by 
special  words,  "  gastroptosis,"  "  nephroptosis,"  "  hepatoptosis,"  "  splen- 
optosis," etc.  Properly,  the  term  ''  enteroptosis"  should  be  employed 
to  describe  prolapse  of  the  intestines  alone,  but  I  shall  follow  the  com- 
mon usage  as  established  by  Glenard. 

Briefly,  ptosis  of  the  abdominal  organs  is  due  to  a  relaxation  of  their 
supports,  so  that  they  sag  from  their  places.  The  consequent  dragging 
upon  vessels  and  nerves  brings  about  certain  changes  in  the  circulation 

1  Parts  of  this  chapter  are  borrowed  from  Surgical  Aspects  of  Digestive  Disorders, 
1907,  by  J.  G.  Mumford  and  A.  K.  Stone. 

243 


244  THE    ABDOMEN 

and  innervation  of  organs,  especially  of  those  organs  in  the  female 
pelvis.  So  the  uterus  may  be  forced  out  of  place,  and  further  distress- 
ing symptoms  may  result.  Moreover,  ptosis  of  the  intestines  removes 
an  important  sup})ort  from  beneath  the  upper  abdominal  oi'gans. 

To  distinguish  cause, and  effect  is  difficult  often,  so  closely  are  the 
various  organs  bound  up  together  and  dependent  upon  one  another, 
antl  the  clinician,  according  to  his  bias,  is  wont  to  regard  a  patient  as 
a  gastric,  gynecologic,  intestinal,  or  nervous  case. 

The  underlying  causes  of  ptosis  are  still  in  dispute,  so  diversified  are 
the  conditions  found,  and  so  great  the  range  of  symptoms  accompany- 
ing them.  In  explanation  of  ptosis  Glenard  suggested  weakness  of  the 
abdominal  nmscles  and  a  loss  of  intra-abdominal  pressure  or  tone, 
which  permits  the  stomach,  intestines,  and  kidneys  to  sag.  Some  writers 
go  further  and  suggest  that  the  displacements  are  congenital,  while 
others  put  the  blame  upon  improper  clothes,  especially  on  corsets  and 
the  bands  of  heavy  skirts;  writers  point  out  also  the  disturbing  effects 
of  pregnancy,  exaggerated  often  by  extensive  rupture  of  the  perineum. 
After  considering  these  statements  and  studj'ing  many  patients,  I 
cannot  but  believe  that  all  such  explanations  are  plausible,  but  that 
rarely  does  any  single  explanation  suffice.  J.  E.  Goldthwait,  in  1909, 
in  a  series  of  brilliant  papers,  showed  how  the  faulty  posture  of  growing 
children  and  of  women  and  young  girls  tends  to  weaken  the  skeletal 
supports  and  to  place  at  a  disadvantage  the  ligaments  and  muscles  of 
the  abdomen  and  back.^ 

Most  women  among  us  wear  their  clothes  without  regard  to  h}'gienic 
considerations.  They  hang  heav}-  skirts  by  narrow  bands  from  their 
waists,  so  that  a  drag  is  brought  upon  the  intestines,  which  lie  in  the 
lower  part  of  the  abdomen.  The  crowded  intestines,  in  turn,  press 
upon  the  pelvic  organs  beneath  them.  Most  corsets  tend  to  exaggerate 
the  waist-line;  they  crowd  down  what  is  below,  and  push  up  what  is 
above.  Straight-front  corsets  do  not  push  the  abdominal  contents 
downward,  as  do  the  old-fashioned  corsets,  though  straight  corsets  even 
may  produce  other  unpleasant  changes  in  the  anatomy'.  Often,  and 
fortunately,  however,  straight-front  corsets,  when  properly  applied, 
may  suffice  to  correct  enteroptosis.  In  the  course  of  physical  examina- 
tion of  elderly  women,  it  is  not  uncommon  to  find  a  permanent  furrow 
made  in  the  costal  margin  by  corset  pressure.  In  view  of  these  facts 
one  cannot  but  conclude  that  bands,  heav}-  skirts,  and  corsets  are 
etiologic  factors  in  ptosis.  One  encounters  other  cases  in  women  whose 
symptoms  all  date  from  childbirth.  Of  such  persons  it  is  probable  that 
many  of  the  dis])lacements  were  present  previously,  but  did  not  become 
troublesome  until  after  the  labor.  The  onset  of  such  s3-mptoms  may 
date  from  the  birth  of  a  first  child,  or  may  be  due  to  a  precipitate  or 
difficult  and  instrumental  delivery.  So  there  are  many  and  various 
causes  of  abdominal  ptosis. 

1  J.  E.  Goldtlnvait,  The  Relation  of  Posture  to  Human  Efficiency  and  the  Influ- 
ence of  Poise  upon  the  Support  and  Function  of  the  Viscera,  Boston  Med.  and  Surg. 
Jour.,  December  9,  1909,  et  seq. 


ABDOMINAL   PTOSIS  245 

It  is  striking,  however,  that  in  spite  of  this  frequency  of  anatomic 
displacements,  syvi])torns  of  ptosis  are  relatively  rare. 

Glenard  errs,  for  no  man  who  has  served  in  a  clinic  for  women  would 
be  willing  to  agree  with  him,  when  he  implies  that  all  palpable  kidneys 
are  pathologic  and  cause  symptoms. 

What,  then,  is  the  process  in  the  development  of  ptosis?  One  can- 
not say  definitely  that  in  this  or  in  that  begins  the  vicious  circle  causing 
prolapse  of  the  abdominal  organs,  yet  in  general  terms  one  m.ay  use  some 
such  description  as  the  following: 

Owing  to  structural  peculiarities,  to  flabby  abdominal  muscles 
weakened  by  severe  illness,  to  improper  clothing,  or  to  pregnancies, 
the  normal  abdominal  tension  is  diminished;  the  transverse  colon  is 
loosened,  usually  at  the  hepatic  flexure,  and  sags  downward;  it  crowds 
the  coils  of  the  small  intestine,  so  that  they  in  turn  press  upon  the  pelvic 
organs.  With  the  loss  of  abdominal  tone  the  whole  colon  then  tends  to 
collapse,  and  this  collapse  extends  even  to  the  rectum,  so  that  there  is 
no  longer  a  dilated  rectal  ampulla  behind  and  below  the  uterus.  The 
muscles  of  the  pelvic  floor  lose  their  resisting  power,  the  uterus  settles, 
and  the  coils  of  the  small  intestine  are  crowded  still  farther  into  the 
pelvis.  There  ensue  modifications  in  the  shape  and  position  of  the  pelvic 
organs,  and  one  finds  a  prolapsed,  retroverted,  and  retroflexed  uterus, 
and  the  various  combinations  familiar  to  gynecologists. 

The  stomach  follows  the  intestines,  for  it  no  longer  receives  their 
normal  support.  As  the  stomach  sinks,  the  aorta  is  left  uncovered  for 
several  inches  above  its  point  of  division.  It  may  be  palpated  and  may 
be  seen  to  pulsate  even.  Indeed,  this  pulsation  is  often  disagreeable 
and  annoying  to  the  patient. 

Sometimes  the  sigmoid  flexure  becomes  dilated  with  retained  feces 
as  a  result  of  intestinal  prolapse.  The  gut  may  expand  greatly,  and 
in  the  course  of  time  may  develop  a  tendency  to  volvulus.  Conse- 
quently, intestinal  obsti-uction  may  ensue,  and  unless  this  is  relieved 
by  high  enemata  and  postural  devices,  there  may  supervene  rapidly  a 
strangulation  demanding  operative  relief.  In  such  case  the  condition 
of  the  patient  may  permit  a  palliative  operation  only;  the  operator 
may  untie  the  obstructing  twist  and  possibly  may  hold  it  by  sutures, 
so  that  the  volvulus  will  not  return.  When  a  patient  suffers  from  re- 
peated similar  attacks,  increasing  in  severity,  operation  must  be  done 
to  anticipate  strangulation.  At  the  operation  it  may  be  necessary 
to  resect  a  portion  of  the  dilated  bowel;  for  often  resection  alone  promises 
a  permanent  cure.  So  after  palliative  operations,  one  may  be  obliged 
to  perform  a  secondary  operation  of  resection. 

Let  us  now  consider  prolapse  of  the  stomach,  which  follows  the  intes- 
tines in  their  fall.  Its  descent  is  favored,  also,  by  the  weight  of  its  con- 
tained food  and  by  the  pressure  of  corsets  and  bands  tending  to  stretch 
the  other  supports  which  hold  it  in  a  more  or  less  vertical  position  nor- 
mally. Consequently,  the  greater  curvature  of  the  stomach  sinks  grad- 
ually, and  the  organ  approaches  the  horizontal.  This  new  position 
results  in  its  dragging  on  the  pylorus  and  the  first  portion  of  the  duode- 


246  THE    ABDOMEX 

num  in  such  a  way  as  to  kink  the  hinicn  of  the  pylorus  and  to  impede 
the  passage  of  food  into  the  intestines.  A  certain  amount  of  gastric 
motor  insufficiency  is,  therefore,  induced.  These  conditions  cause  a 
further  descent  of  the  stomach,  because  motor  insufiiciency  results  in 
its  being  kept  loaded  longer  than  usual.  Gas-foi-mation  and  stomach 
distention  result,  as  well  as  a  frequent  tendency  to  hypei'acidity,  with 
the  attendant  possibilities  of  ulcer  formation.  It  is  said  that  this  last 
danger  is  especially  to  be  feared  when  floating  kidney  is  associated  with 
gastroptosis. 

As  the  general  ptosis  jDrogresses  the  stomach  descends  into  the  ab- 
dominal cavity  until  its  greater  curvature  is  well  below  the  umbilicus. 
What  is  more  to  the  point,  for  diagnostic  purposes,  the  upper  border  of 
the  stomach  will  then  be  low  in  the  epigastric  region. 

Ptosis  of  the  stomach  may  exist  without  giving  rise  to  an}-  dj-.speptic 
symptoms;  indeed,  gastroptosis  does  not  necessarily  imply  gastric  dila- 
tation. That  a  prolapsed  stomach  may  be  normal  in  size  can  be  demon- 
strated b}^  the  examination  of  young  and  thin  women.  Moreover, 
moderate  motor  insufficiency  ma}-  exist  without  associated  dilatation. 
Frequenth',  in  the  case  of  a  markedh'  prolapsed  stomach,  when  dyspep- 
tic symptoms  are  present,  they  nm}'  be  relieved  quickly  b}-  a  proper 
diet,  proper  exercises,  and  massage. 

One  will  find  gastric  dilatation  added  speedih-  to  prolapse  in  those 
cases  in  which  dyspeptic  s3'niptoms  are  not  checked  by  proper  treatment. 
The  prolapsed  stomach  drags  on  the  pj-lorus,  so  that  there  results  a  per- 
manent kinking  and  narrowing  of  the  p}'lorus.  These  cases  of  stomach 
ptosis,  plus  dilatation,  must  be  studied  carefully  if  one  would  recognize 
the  presence  of  the  two  associated  conditions,  ptosis  and  dilatation.  Evi- 
dence of  stasis  and  an  increase  in  the  amount  of  h3'drochloric  acid 
are  present,  except  occasionally  in  long-standing  cases.  The  capacity 
of  such  a  stomach  is  increased. 

In  the  case  of  such  a  stomach  there  exists  a  genuine  pjdoric  stenosis — 
a  stenosis  as  baneful  as  that  caused  by  a  cicatrized  ulcer.  Some  form 
of  operation  is  needed  for  the  cure,  and  the  choice  of  operation  should  be 
governed  by  the  rules  laid  down  in  Chapter  IV. 

Moreover,  special  operations  have  been  devised  for  ptosis  of  the  stom- 
ach. The  gastrohepatic  ligament,  stretched  by  the  descent  of  the  stom- 
ach, has  been  shortened  by  Beyea  and  sundry  other  surgeons.  They 
pass  sutures  so  as  to  bring  the  pyloiTis  close  up  to  the  under  surface  of 
the  liver.  The  first  suture  includes  both  the  cap.sule  of  the  liver  and  the 
outer  coats  of  the  stomach.  Beyond  this  point  the  gastrohepatic  lig- 
ament and  the  lesser  omentum  are  infolded  so  as  to  raise  the  stomach 
and  make  its  upper  border  resume  the  normal  position.  It  is  suggested 
that  one  should  fasten  up  the  colon  at  the  same  time,  else  will  the 
stomach  lack  its  old  support  beneath. 

Of  all  the  abdominal  organs  subject  to  ptosis,  the  kidney  receives 
most  attention — more  attention,  relatively,  than  it  merits. 

The  wisdom  of  routine  operating  for  nephroptosis  is  in  dispute.  In 
a  routine  series  of  272  women  recently  examined  clinically  at  the  Boston 


ABDOMINAL   PTOSIS  247 

City  Hospital  Larrabee  found  that  112  cases,  or  41.5  per  cent.,  had  mov- 
able kidneys.  At  the  Massachusetts  General  Hospital  in  1904  Pratt 
looked  for  ptosis  in  all  cases  coming  to  his  clinic,  and  found  that  96,  or 
32  per  cent.,  out  of  271  women  were  the  subjects  of  movable  kidney. 
Such  has  been  the  experience  of  many  others.  Nephroptosis  in  men  is 
more  frequent  than  is  commonly  supposed.  Floating  kidneys  have 
been  found  in  children. 

Most  women  with  movable  kidneys  are  unaware  of  renal  disturbance; 
such  symptoms  as  they  have  are  not  referred  distinctly  to  the  displaced 
organ.  On  the  other  hand,  though  a  patient  have  a  kidney  prolapsed  in 
the  first  degree  only,  that  errant  kidney  may  cause  severe  symptoms. 
The  case  is  parallel  to  that  of  a  patient  with  a  breaking-down  plantar 
arch  of  the  foot.  When  a  foot  is  beginning  to  break  down,  the  resulting 
symptoms  may  be  severe  enough  to  call  urgently  for  relief.  So  with  a 
kidney  beginning  to  slip.  Rarely,  indeed,  will  slight  displacements  of 
the  kidney  require  operation,  but  the  physician  must  not  forget  that 
operation  eventually  may  be  demanded. 

When  slight  displacements  cause  acute  symptoms,  one  will  find  often 
that  the  ptosis  is  due  to  an  injury,  to  a  fall,  a  strain,  or  a  wrench  of  the 
bod}^,  or  to  heavy  lifting.  A  prolonged  bicycle  ride  has  been  known  to 
induce  acute  symptoms  of  nephroptosis.  In  making  the  diagnosis, 
assure  yourself  that  the  kidney  is  at  fault,  and  that  you  are  not  dealing 
with  a  lesion  of  the  sacro-iliac  joint. 

Another  aspect  of  renal  ptosis  is  that  presented  by  a  kidney  long 
recognized  as  floating,  and  hitherto  harmless,  which,  on  a  sudden,  causes 
severe  and  distressing  symptoms.  The  symptoms  may  be  so  serious 
as  to  suggest  appendicitis;  and,  seen  after  the  acute  symptoms  have  sub- 
sided, there  may  remain  so  much  local  tenderness  as  to  puzzle  the 
physician  and  leave  him  in  doubt  whether  the  appendix  or  the  kidney 
be  at  fault. 

Clinicians  talk  of  "  Dietl's  crises"  as  characteristic  of  floating  kidney. 
DietFs  crises  are  supposed  to  be  due  to  a  twist  or  kink  in  the  renal 
vein.  Some  experimenters  believe  a  kink  in  the  ureter  to  be  the  more 
usual  cause. 

Whatever  the  explanation,  it  is  a  fact  that  in  a  number  of  cases  in 
wdiich  there  is  a  floating  kidney  there  are  repeated  attacks  of  pain  and 
distress.  These  attacks,  or  Dietl's  crises,  begin  frequently  with  a  sense 
of  weight  and  discomfort  below  the  border  of  the  ribs  and  near  the  me- 
dian line;  sometimes  the  first  symptoms  are  pain  in  that  region,  and  nausea 
followed  by  vomiting.  If  the  symptoms  persist,  the  affected  area  soon 
becomes  tender,  so  that  one  suspects  peritonitis.  Often  the  patient 
experiences  palpitation  of  the  heart;  the  symptoms  become  very  dis- 
tressing; sometimes  the  mental  condition  suggests  hysteria.  The  crisis 
may  persist  unabated  for  several  days,  or  it  may  last  but  a  few  minutes. 
Frequently  one  may  replace  the  kidney  and  relieve  the  sj-mptoms  by 
removing  the  clothes,  by  posture,  and  by  manipulation,  the  patient 
being  in  a  hot  bath  if  necessary. 

The  experienced  observer  will  notice  that  these  symptoms  are  simflar 


248  THE    ABDOMEN 

to  those  seen  in  the  gall-stone  attacks  caused  by  a  calculus  attenij)ting 
to  engage  in  the  cystic  duct,  but  not  passing  out  of  the  gall-bladder. 
Such  hepatic  colic  is  relieved  usually  by  measures  similar  to  those  just 
described.  It  is  associated  with  no  other  distinctive  features  of  gall- 
stone disease,  as  jaundice  or  tumor  of  the  gall-bladder. 

Recurring  renal  crises  make  life  a  burden.  The  unfoitunate  victim 
never  knows  when  or  where  the  attack  may  seize  her.  When  it  comes, 
she  must  be  prepared  to  loosen  her  clothes,  apply  heat,  and  call  for  the 
masseuse. 

As  the  prolapsed  kidney  may  come  in  contact  with  the  bile-passages 
above,  so  it  may  drop  upon  the  appendix  below.  The  appendix  lies 
in  its  path.  We  have  told  how  one  may  mistake  a  tender  kidney  for  a 
diseased  appendix;  more  than  that,  an  errant  kidnej-  niay  actually 
irritate  the  appendix  and  so  cause  a  chronic  appendicitis.  So  we  nmst 
stud}'  carefully  the  nature  of  recurring  pains  in  the  renal-appendix 
region.  Renal  crises  do  not  kill  chronic  appendicitis  may  become  acute 
and  lethal  at  any  moment.  Inflamed  retroperitoneal  lymph-nodes  and 
stone  in  the  right  ureter  also  may  give  rise  to  symptoms  suggesting  renal 
ptosis  or  appendicitis. 

A.  T.  Cabot  pointed  out  that  hematuria  may  result  from  ptosis  of 
the  kidney.  Sometimes  the  bleeding  is  profuse  and  alarming;  sometimes 
it  is  slight,  but  constant.  For  this  hematuria  we  must  operate ;  and  when 
we  have  the  kidney  exposed  and  in  hand,  we  must  not  forget  to  look  in 
its  pelvis  for  a  small  calcareous  scale  which  the  x-ray  has  not  shown. 

The  treatment  of  floating  kidney  involves  the  treatment  of  general 
abdominal  ptosis  in  a  great  many  cases.  One  must  study  all  the  symp- 
toms of  the  patient.  Often  one  must  perform  an  exploratory  operation 
in  order  to  make  a  diagnosis.  By  anchoring  the  kidney,  biliary  and 
appendiceal  symptoms  will  be  relieved  frequently;  therefore,  when  the 
symptoms  are  complex  and  obscure,  it  is  well,  for  the  sake  of  explora- 
tion, to  open  the  abdominal  cavity  in  front.  Thus  mistakes  will  be 
avoided.  So  there  are  certain  invalids,  few  in  comparison  with  the  num- 
ber of  persons  with  displaced  kidneys — certain  invalids  who  really 
do  have  so  much  trouble  from  persistent  hematuria,  from  the  frequency 
of  their  renal  crises,  or  from  the  constant  dragging  sensation  and  the 
burning  pain  along  the  line  of  the  iliohypogastric  nerve  that  they  merit 
operation.  The  patient  may,  indeed,  be  nervous  and  irritable — what 
wonder! — but  the  pain  and  discomfort  are  constant  and  are  found  in  the 
same  location  always.  The  true  neurasthenic  element  is  lacking.  Such 
a  patient  may  be  a  permanent  invalid,  nearly  bedridden,  alwaj's  debarred 
from  prolonged  exertion,  and  cut  off  from  the  possibility  of  earning  a 
livelihood.  Operation  will  generally  relieve  the  sufferer,  and  her  chance 
of  cure  by  operation  is  very  good  indeed. 

But  most  displaced  kidneys  do  not  require  an  operation.  In  order 
to  replace  the  prolapsed  organs,  lay  the  patient  on  her  back,  with  the 
hips  elevated — in  a  modified  Trendelenburg  position;  manipulate  and 
knead  the  organs  into  place, — stomach,  kidney,  or  intestines, — and  then 
bind  them  in  position  with  the  bandage. 


ABDOMINAL   PTOSIS  249 

What  bandage  shall  be  used?  There  is  the  difficulty.  There  has 
been  a  great  deal  of  discussion  of  that  question,  and  experiment  and 
failure  to  find  the  correct  bandage.  Here  is  a  simple  device,  which  I 
have  found  satisfactory:  Apply  a  roller  bandage  to  the  abdomen  just 
as  one  would  apply  a  roller  bandage  to  the  arm.  The  abdominal 
roller  should  be  of  flannel,  cut  straight,  6  inches  wide,  and  from  6  to 
10  yards  long.  Before  beginning  to  apply  it  see  that  the  patient  is 
properly  elevated  and  that  the  viscera  are  rolled  up  toward  the  dia- 
phragm. Begin  bandaging  by  taking  a  binding  turn  about  the  patient's 
thigh;  then  quickly,  smoothly,  and  firmly  bandage  the  abdomen  from 
pubes  to  ensiform.  The  bandage  must  lie  fairly  tight  at  the  bottom  of 
the  belly,  but  looser  at  the  top.  It  fits  perfectly;  it  feels  snug  and 
secure.     The  patient  will  experience  relief  almost  instantly. 


Fig.  133. — Showing  two  of  the  four  suspension  sutures  passed  through  reflected 
and  attached  layers  of  capsule  proper,  without  penetration  of  kidney  substance. 
The  two  companion  sutures  passed  on  the  opposite  face  of  the  kidney  are  not  shown 
(Edebohls). 

If  this  bandage  is  satisfactory  and  the  patient  wishes  to  go  on  with 
such  treatment,  the  physician  may  have  constructed  an  easily  applied 
belt,  but  the  patient  will  find  no  apparatus  so  comfortable  as  the  simple 
roller  bandage.  The  straight-front  corset,  properly  fitted,  is  favored 
by  many  clinicians  and  is  successful.  There  remain  those  few  cases 
which  bandages  do  not  relieve;  in  which,  if  the  kidney  is  obviously  at 
fault  and  its  fixation  is  demanded,  the  surgeon  had  best  operate.  He 
should  approach  the  renal  region  through  a  lumbar  incision.  Many 
different  operations  have  been  devised  and  advocated  for  anchoring 
the  kidney.  The  commonest  error  is  to  fasten  that  organ  too  high. 
Normally,  the  kidney  has  an  excursion  of  from  1^  to  2  inches,  so  that 
it  is  well  to  anchor  it  at  the  low^est  point  of  its  normal  excursion.     If 


250 


THE   ABDOMEN 


fixctl  too  high,  it  "svill  continue  to  l)e  the  subject  of  pain  and  \vill  be  more 
easily  pounded  loose  by  the  moving  liver  above  it. 

Cut  down  upon  the  kidney  through  the  back  on  the  outer  side  of  the 
quadratus  lumborum  muscle;  tear  thiough  the  fatty  capsule;  pull  the 
kidney  out  of  the  wound;  split  its  fibrous  capsule  from  pole  to  pole,  and 
decapsulate  the  organ  nearly  to  the  hilus;  then  pass  silk  or  chromic- 
gut  stitches  (it  matters  little  which)  through  the  loosely  hanging  cap- 
sule, as  indicated  in  the  illustration,  and  thus  swing  the  kidney  by 
capsule  and  stitches  from  the  back  muscles.  By  emplo3'ing  these  mea- 
sures you  will  not  penetrate  and  lacerate  the  kidney  tissue.'  Then 
close  the  wound  in  the  back  b}'  la^^ers.  These  operations  on  the  kidneys 
are  facilitated  by  placing  a  hard  roimd  bolster  beneath  the  upper  por- 
tion of  the  abdomen,  as  the  patient  lies  on  his  belly.     The  fixed  kidney 


Fig.    1-34. — Edebohls'  kidney  air-cushion,  and  patient  in  position  for  ojioration. 


may  break  away  from  its  new  attachments  if  the  patient  moves  about 
too  soon.  It  is  my  custom  to  keep  him  on  his  back,  or  on  the  affected 
side,  wuth  the  head  low,  for  at  least  three  weeks  after  the  operation. 
In  the  few  properly  selected  cases  foi-  which  one  does  nephropexy  the 
results  are  gratifying.  Pain  is  relieved,  and  the  constantly  recurring 
dyspeptic  symptoms  are  banished. 

In  the  chapters  on  Diseases  of  the  Liver  and  the  Spleen  I  have  dis- 
cussed ptosis  of  those  organs.  Suffice  it  hei'e  to  remind  the  I'cader  that 
wandering  spleen  is  I'are — rarer  than  floating  liver;  that  removal  of 
the  spleen  generally  is  necessary  for  cure,  and  that  as  yet  in  spite  of 
many  ingenious  devices  for  anchoring  the  liver,  we  have  not  developed 
a  treatment  altogether  satisfactor}-  for  the  distressing  condition,  hepato- 
ptosis  with  the  associated  displacement  of  other  organs.     AVhen  con- 

'  This  is  essentially  the  operation  of  Edebohls. 


THE   ABDOMINAL    WALL  251 

fronted  with  sucli  general  i)toacs,  tr}-  first  the  abdominal  bandage  I 
have  described  in  thi.s  chapter;  have  the  patient  wear  it  dail}',  and  have 
it  applied  with  the  patient  in  a  modified  Trendelenburg  poi^ition.  Such 
treatment  gives  comfort,  even  when  it  does  not  cure. 

THE  ABDOMINAL  WALL 

Diseases  and  injuries  of  the  abdominal  wall  find  their  place  in 
books  of  surgery,  and  of  late  years  this  subject  has  been  given  much 
attention  by  painstaking  writers.  For  my  own  part,  I  cannot  see  that 
such  lesions,  with  two  or  three  exceptions,  deserve  special  attention, 
because  injuries,  inflammations,  and  new -growths  of  the  abdominal 
wall  are  much  like  similar  phenomena  elsewhere. 

The  practitioner  should  remember  the  general  anatomic  structure 
of  the  abdominal  wall — how  it  is  massive  and  unyielding  behind,  thin 
and  elastic  in  front,  with  the  anterior  surface  of  the  lumbar  vertebrse 
nearer  to  the  umbilicus  than  to  the  skin  of  the  back  in  average  individ- 
uals. The  broad-lying  muscles  and  dense  aponeuroses  of  the  abdominal 
wall  favor  the  limitation  of  inflammations  to  special  planes;  and  the 
gridiron-like  arrangement  of  the  muscles  as  the}^  he  one  above  the 
other  seems  assigned  ingeniously  to  streng-then  the  wall  and  prevent  the 
development  of  hernise,  even  after  severely  lacerating  wounds. 

The  greatest  interest  in  injuries  of  the  abdominal  wall  centers  in  the 
possibility  of  lesions  to  the  underlying  viscera.  That  is  a  matter  which 
we  have  discussed  in  Chapter  II. 

Contusions  ^  of  the  wall  are  frequent  and  may  result  in  extensive 
tearing  of  muscles  and  the  formation  of  great  hematomata.  The 
symptoms  are  usually  slight,  and  the  treatment  consists  in  absolute  rest 
and  the  application  of  cold.  Sometimes  it  is  necessar}^  to  aspirate  off 
collected  blood.  The  prescribing  of  rest  is  essential  mainly  because  it 
is  not  always  obvious  whether  or  not  the  underlying  viscera  are  in- 
volved. 

Penetrating  and  lacerating  wounds  of  the  abdominal  wall  should 
be  treated  thoroughly.  The  patient  should  be  etherized,  if  necessary, 
the  wound  opened  and  explored  carefully,  cleaned,  and  sewed  up, 
with  or  without  drainage,  depending  upon  the  amount  of  laceration 
and  soiling  of  the  parts.  If  several  layers  of  muscle  and  aponeurosis 
are  damaged,  the  wound  should  be  closed  in  layers,  with  careful  approxi- 
mation to  avoid  subsequent  hernia. 

Inflammation  of  the  abdominal  wall  is  a  somewhat  favorite  topic 
with  writers,  and  here  again  the  significance  of  the  lesion  is  important 
mainly  on  account  of  the  possibility  of  damage  to  deeper  structures. 
These  inflammations  may  be  superficial  or  deep.  If  superficial,  they 
may  often  be  cured  by  the  Bier  treatment,  hy  vaccine  therapj',  or  b}- 
hot  applications  merely;  but  if  obstinate,  and  especially  if  pus  has 
formed,   the  abscess  must  be  opened  and  evacuated.     JJhi  pus,  ibi 

1  See  Charles  L.  Scudder,  Contusions  of  the  Abdomen,  Boston  Med.  and  Surg. 
Jour.,  May  2,  1901.     He  gives  a  valviable  bibliography. 


252  THE   ABDOMEN 

evacua,  holds  true  here  as  elsewhere.  The  infections  deep  in  the  alxlom- 
inal  wall  may  be  of  serious  consequence,  as  they  may  involve  such  im- 
portant localities  as  the  prevesical  space  or  the  region  about  the  kidneys. 
The  evidence  of  such  deep  infection  is  two-fold — constitutional  and 
local.  There  is  a  ''  pus  temperature,"  high  at  night  and  low  in  the  morn- 
ing, with  a  corresponding  variation  in  the  pulse-rate,  constant  leuko- 
cytosis, debility,  wasting.  Locally,  there  is  increasing  swelling,  with 
pain  and  tenderness,  except  where  the  inflammation  is  confined  by  dense 
aponeuroses.  In  the  case  of  deep  inflammation,  thorough  ojK'uing  with 
drainage  is  imperative. 

There  may  be  special  forms  of  chronic  inflammation,  \\ith  ulceration 
of  the  abdominal  wall,  from  such  infections  as  tuberculosis;,  syphilis, 
and  actinom3'-cosis.  Actinomycosis  especially  is  interesting.  It  comes 
usually  by  way  of  the  intestinal  canal.  The  gut  becomes  adhei'ent  to 
the  parietes;  the  disease  spreads  outward;  fistulse  may  form,  and  an 
extensive  involvement  simulating  malignant  disease  may  I'esult.  In 
Chapter  II  is  described  a  case  which  I  saw  recently  in  the  hands  of  a 
colleague — one  of  those  cases  which  has  all  the  gross  appearance  of  sar- 
coma involving  the  intestine  and  the  abdominal  wall.  The  case  seemed 
hopeless;  but  extensive  dissection  of  the  abdominal  wall  showed  the 
mass  to  be  an  inflammation  arising  from  the  intestine,  through  which 
an  infecting  fish-bone  had  penetrated.  The  general  forms  of  inflammation 
must  be  treated  on  general  principles.  Tuberculosis  of  the  parts  may  be 
cureted,  dressed  with  iodoform,  and  the  patient  given  an  out-of-doors 
life.  S3'philitic  ulcers  must  be  dressed  with  iodoform  or  aristol,  and  the 
patient  given  full  doses  of  potassium  iodid,  20  to  90  grains  daily.  The 
treatment  of  actinomycosis  is  not  purely  operative:  we  open  up  fistulse 
and  dissect  out  involved  tissue,  and  I  supplement  the  operative  treat- 
ment by  the  method  of  the  Be  van  clinic — "  where  a  relatively  large 
number  of  cases  have  been  treated  lately  (and),  excellent  results  have 
followed  the  use  of  copper  sulphate  administered  in  a  quarter-grain  pill, 
three  times  a  day,  and  irrigation  of  the  focus,  when  possible,  with  a  1 
per  cent,  solution  of  copper  sulphate." 

Tumors  of  the  abdominal  wall  are  of  three  main  varieties — cow- 
nective-tissue  tumors,  desmoids,  and  epithelial  tumors. 

The  connective-tissue  tumors  ar'e  angionmta,  fibromata,  lipovrnta,  and 
sarcomata.  They  must  be  treated  by  removal.  The  lipotnata  are  the 
most  common;  they  are  usually  well  incapsulated,  and  can  be  easily 
removed  by  splitting  and  enucleation. 

Desmoid  tumors  are  the  most  interesting  growths  in  this  region. 
They  spring  from  tendinous  tissue,  such  as  the  aponeui'oses  or  the 
transverse  tendinous  tissue  of  the  recti  muscles.  These  tumor  masses 
usually  are  hard,  and  creak  on  being  cut.  The  cut  surface  glistens 
and  shows  numerous  fibrous  bands  crossing  each  other  at  right  angles. 
Sometimes  the  tumors  contain  cysts.  They  are  usually  found  in  women, 
the  proportion  of  women  to  men  being  as  9  is  to  1 ;  and  most  of  the 
women  affected  are  those  who  have  borne  children.  Desmoids  are 
usually  found  near  the  median  line  and  are  single.     They  must  not  be 


THE   ABDOMINAL    WALL  253 

conf()un(l(Hl  with  fibromyoniatti  of  the  round  h'gament,  which  may  grow 
within  the  inguinal  canul.  'J'he  .'•;y7tiptovis  of  desmoids  ai'c  ckic  to  pressure 
onl}',  for  the  tumor  may  reach  a  considerable  size,  and  interfei-e  with  the 
action  of  the  intestines  and  bladder.  The  treatment  of  desmoids  is  their 
complete  removal — they  do  not  give  rise  to  metastases,  and  the  only 
point  of  interest  in  their  removal  is  the  control  of  hemorrhage,  which 
may  be  considerable. 

Epithelial  tumors  of  the  abdominal  trail  ai'c  not  uncommon.  Der- 
moid and  sebaceous  cysts  occur  near  the  umbilicus,  and  can  be  removed 
easil}'  under  local  anesthesia.  Primary  cancer  occurs  also  in  this  region, 
and  should  be  removed  radically.  Secondary  cancer  from  the  abdominal 
organs  sometimes  involves  the  abdominal  wall. 

Echinococcus  is  rarely  a  disease  of  the  abdominal  wall.  It  gives  rise 
to  locaHzed  swelling,  malaise,  and  wasting.  The  only  rational  treatment 
is  incision,  evacuation,  and  removal  of  the  sac,  if  possible,  or  its  packing 
with  gauze  to  promote  granulation  from  the  bottom. 

Pendulous  abdomen  scarcely  deserves  to  rank  as  a  disease,  but  it 
is  a  condition  sometimes  submitted  to  operation.  A  vast,  flabby,  low- 
lying  mass  of  fat  in  the  abdominal  wall  may  cause  invalidism,  practic- 
ally, and  may  be  removed. 

Malformations  of  the  umbilicus  and  urachus  are  not  infrequently 
subjects  for  surgery,  and  the  commonest  form  of  malformation  is 
faulty  closure  of  the  vitello-intestinal  duct.  The  vitello-intestinal  duct, 
by  which  the  bowel  of  the  embryo  communicates  with  the  yolk-sac, 
disappears  usually  at  about  the  eighth  week  of  fetal  life,  but  it  may  per- 
sist and  result  in  sundry  abnormalities,  such  as  fistula  at  the  navel, 
diverticulum,  or  cyst.  Such  an  abnormality  may  be  evident  when  the 
umbilical  cord  drops  from  a  new-born  infant,  or  a  fistula  may  develop 
weeks  later.  If  one  of  these  embryonic  passages  exists,  it  springs  always 
from  the  small  intestine,  usually  from  the  lower  third  of  the  ileum. 
If  the  duct  is  closed  inside  the  abdomen,  but  persists  in  the  umbiHcal 
cord,  there  will  remain,  after  the  cord  falls,  a  tumor  discharging  mucus 
from  its  surface — hence  the  misnomer,  enteroteratoma. 

If  the  malformation  is  not  extensive  or  specially  troublesome,  it 
may  be  treated  by  palliation.  Sometimes  cleansing  lotions,  applica- 
tion of  the  cautery,  and  close  strapping  of  the  wound  may  cause  an  ob- 
literation of  the  fistula.  It  is  not  wise  to  perform  upon  a  new-born  baby 
an  extensive  radical  operation  for  such  a  deformity.  If  mild  measures 
do  not  avail,  a  radical  operation  may  be  done  later — after  the  sixth 
month  of  life.  Dissect  out  the  umbilicus,  explore  the  abnormality, 
remove  the  duct  from  the  intestine,  and  close  the  intestinal  wound  in  the 
ordinary  way.     The  operation  is  a  major  one,  and  may  be  fatal. 

A  somewhat  similar  malformation  of  the  urachus  sometimes  exists 
— the  communication  between  the  urinary  bladder  and  the  allantois. 
This  urachus  or  duct  becomes  obliterated  early  in  embryonic  life,  but 
may  remain  patent  and  discharge  urine  at  the  umbilicus  after  birth. 
Sometimes  partial  obliteration  of  the  urachus  occurs,  so  that  there 
develops  a  blind  fistula  in  some  portion  or  a  cyst  of  the  urachus.     More 


254  THE   ABDOMEN 

rareh'  similar  conditions  may  be  brought  about  after  birth  and  are 
associated  with  or  dependent  on  some  obstruction  to  the  normal  out- 
flow of  urine  through  the  urethra.  AA'ith  all  these  conditions  there  may 
be  a  coincident  cystitis.  Treatment  must  overcome  obstruction  to  the 
urethra;  it  must  cure  the  cystitis,  and  must  remove  the  patent  urachus, 
by  some  such  operation  as  we  emplo}'  in  dealing  with  the  patent  vitello- 
intestinal  duct. 

Infections  and  inflammations  about  the  umbilicus  arc  common, 
especially  in  the  new-boru,  and  the  most  frequent  cause  is  filth — a  neg- 
lected collection  of  sweat  and  dirt  in  the  umbilical  pit.  The  obvious 
remedy  is  cleansing,  antiseptic  washes,  poulticing,  and  incision  if  neces- 
sary. At  any  period  of  life  an  inflamed  umbilical  fistula  may  develop, 
for  the  umbilicus  is  the  thinnest  portion  of  the  abdominal  wall,  and  is  a 
favorite  seat  for  the  escape  of  pus  from  an  intra-abdominal  abscess. 
Such  a  fistula,  depending  on  its  origin,  may  also  discharge  feces,  urine, 
or  bile.  It  may  close  spontaneously,  on  which  account  any  radical 
operation  for  its  cure  should  be  delayed  for  six  months  at  least. 

Tumors  of  the  tunbilicus  are  not  uncommon.  These  are  the 
inflammation  tumors — the  granulomata  of  infanc}'  and  the  papillary 
fibromata  of  later  life.  A  granuloma  is  sometimes  called  an  umbilical 
fungus;  it  must  be  distinguished  from  an  enteroteratoma,  which  does 
not  present  granulations,  but  is  covered  with  mucous  membrane.  The 
granuloma  may  be  cured  by  cleansing  and  touching  with  silver  nitrate, 
or  it  may  be  snipped  off  with  scissors  and  the  wound  di'essed  with  dry 
gauze. 

The  papillary  fibroma  of  adult  life  is  a  firm  tumor  with  a  pedicle.  It 
may  grow  as  large  as  a  walnut,  and  may  become  maligiiant.  It  must 
be  excised  thoroughly. 

Connective-tissue  tumors  of  the  umbilicus  occasionally  are  reported, 
but  they  are  rare,  especially  the  non-malignant  forms.  Sarcoma  or  fibro- 
sarcoma is  somewhat  more  common  than  the  benign  forms  of  connective- 
tissue  tumors.  Epithelial  tumors  of  the  umbilicus  have  been  mentioned 
already  in  this  chapter. 

The  foregoing  paragraphs  make  plain  the  fact  that  there  is  now  a  con- 
siderable literature  on  the  abdominal  wall,  but  there  is  no  great  interest 
in  the  matter,  and  with  the  exception  of  those  curious  abnormalities 
and  malformations  connected  with  the  umbilicus,  the  subject  merits  no 
more  than  a  cursory  discussion. 


PART  II 

FEMALE  ORGANS  OF  GENERATION 


CHAPTER  X 

THE  UTERUS 

The  general  surgeon  sees  and  treats  uterine  disease,  in  spite  of  the 
fact  that  gynecology  has  long  been  regarded  as  a  specialty.  I  do  not 
propose  to  deal  elaborately  with  gynecologic  problems  in  the  following 
three  chapters,  but  to  discuss  briefly  the  more  important  lesions  of  the 
female  organs  of  generation.  The  uterus,  tubes,  and  ovaries  are  abdom- 
inal organs,  often  involved  with  diseases  of  other  organs,  often  them- 
selves subjects  for  radical  operations  which  every  surgeon  must  under- 
take. 

ANATOMY 

The  anatomy  of  the  pelvic  viscera  is  important,  but  in  this  brief 
treatise  we  have  space  for  a  few  suggestions  only.  Surgeons  are  wont 
to  regard  the  topography  of  these  organs  from  two  points  of  view — 
that  from  above  through  the  abdominal  wall,  and  that  from  below 
through  the  pelvic  floor. 

It  is  needless  to  discuss  the  anatomy  of  the  abdominal  wall  as  one 
approaches  the  uterus  from  above,  though  I  cannot  forbear  referring 
the  reader  to  Max  Brodel's  beautiful  plates  in  Howard  A.  Kelty's 
Operative  Gynecology.  Suffice  it  to  say  that  the  patient  should  be 
placed  in  the  Trendelenburg  position,  whenever  work  through  an 
abdominal  wound  is  to  be  done  in  the  pelvis.  By  the  aid  of  that 
position,  the  intestines — usually  the  ileum — may  be  easily  held  up 
out  of  the  pelvis.  When  the  beginner  approaches  the  normal  uterus, 
he  is  surprised  to  find  it  Ijang  at  an  apparently  unusual  depth,  far 
from  the  abdominal  wall.  It  is  in  a  position  of  ante  version,  with 
the  rounded  cone  of  its  fundus  behind  the  sj-mphysis.  Grasp  the 
fundus  with  double  hooks  and  draw  it  up  into  the  wound,  when 
you  will  see  three  important  structures  centering  at  either  side  of  it, 
and  enveloped  in  the  broad  ligament — three  structures:  from  before 
backward,  the  round  ligament,  the  Fallopian  tube,  and  the  ovarian  lig- 
ament. The  bladder  lies  independently-  in  front  of  the  womb;  it  seems 
to  be  part  of  the  abdominal  wall,  for  it  is  outside  of  the  peritoneum, 
and  should  have  been  emptied  so  as  to  cause  its  disappearance,  almost, 
before  the  operation.    The  rectum,  more  clearly  defined  than  the  bladder, 

255 


256 


FEMALE  ORGANS  OF  GENERATION 


drops  straight  tlown  behiiul  the  uterus.  The  uterosacral  hganients 
spring  from  the  ix)sterior  aspect  of  the  uterus  and  pass  on  cither  side 
of  the  rectum  to  their  sacral  attachments.     Now,  if  j^ou  dissect  carefully 


I'ig.    13."). — I'atii'iit    in  I'rciult'lfuliuii;'   llCl^<ili^ln — c-orrcct.     Kiu-t'.^  f^traiglit. 

away  the  bi'oad  ligaments,  or  s})lit  them,  you  will  find  the  ureters  deeply 
placed,  running  over  the  true  brim  to  the  bottom  of  the  pelvis,  where  they 


Fig.   1.30. — Patient  in  Tienilelenburg  position — incorrect.     Knees  flexed. 

pass  on  either  side  of  the  cervix  uteri  to  enter  the  base  of  the  bladder. 
As  the  ureters  pass  the  pelvic  brim  they  rest  upon  the  common  iliac 
arteries.     The  ureters  must  be  spared  in  the  operation  of  h}-sterectomy. 


ANATOMY 


257 


The  blood  and  lymphatic  connections  of  the  uterus  are  important 
and  interesting.  You  may  demonstrate  the  blood-vessels  by  an  easy 
dissection.  The  student  should  learn  accurately  to  determine  the  posi- 
tion of  the  ovarian  arteries.  They  arise  commonly  from  the  aorta, 
though  the  left  ovarian  artery  sometimes  springs  from  the  left  renal 
artery.  Passing  down  along  with  the  ureters,  they  enter  the  suspensory 
ligament  of  the  ovar}-.  The  ovarian  veins  on  the  right  side  empty  into 
the  vena  cava,  while  on  the  left  side,  following  the  analogy  of  the  left 
spermatic,  they  discharge  themselves  into  the  left  renal  vein.  The 
uterine  arteries  are  somewhat  larger  and  more  important  structures 


:s*^ 


Fig.  137. — Walling  off  with  gauze,  patient  in  Trendelenburg  position. 


than  are  the  ovarian  arteries,  and  their  dissection  is  not  always  easy. 
They  spring  from  the  anterior  trunk  of  the  internal  iliac  artery,  deep  in 
the  pelvis,  and  follow  a  short  course  to  the  cervix  uteri,  where  thej' 
enter  the  body  of  the  uterus,  giving  off  numerous  branches,  one  of  which 
is  the  vaginal.  The  ureter  lies  below  the  uterine  artery  and  two  of  its 
veins,  but  above  the  large  vaginal  artery  and  uterine  vein.  The 
branches  of  the  uterine  vessels  anastomose  with  the  branches  of  the 
ovarian,  both  in  the  broad  ligaments  and  in  the  body  of  the  utems 
itself. 

The  lymphatic  connections  of  the  uterus  and  vagina  are  abundant, 
17 


258 


FEMALE  ORGANS  OF  GENERATION 


and  seem  at  first  to  follow  no  ijarticular  arrangement.  One  finds  on 
careful  study,  however,  that  lymphatic  drainage  from  the  lowest  part  of 
the  vagina  passes  to  the  inguinal  lymph-nodes,  and  through  these  to  the 
system  of  nodes  along  the  external  iliac  arteries.  The  lymphatic  chan- 
nels from  the  upper  portion  of  the  vagina  and  lower  part  of  the  cervix 
follow  the  uterine  vessels  and  so  form  part  of  the  internal  iliac  system, 
finally  joining  the  external  iliac  system  near  the  bifurcation  of  the  com- 
mon iliac  artery.     The  lymph-vessels  from  the  body  of  the  uterus  follow 


Fig.  13S. — Showing  deep  and  superficial  muscles  of  the  perineum  (after  Sobotta). 

two  courses — either  along  the  round  ligaments  and  so  to  the  inguinal 
nodes,  or  along  the  ovarian  vessels,  the  suspensory  ligament  of  the  ovarj^. 
and  thus  up  to  the  lumbar  nodes.  Se  we  see  that  lymphatic  channels 
from  the  lowest  portion  of  the  vagina,  as  well  as  from  the  fundus  of  the 
uterus,  deposit  their  material  eventually  in  the  lumbar  nodes,  which 
lie  high  in  the  abdomen,  upon  the  front  of  the  aorta,  in  the  region  of  the 
kidneys.  The  reader  will  recall  our  brief  discussion  of  the-se  lumbar 
lymph-nodes  in  Chapter  VHI,  when  we  dealt  with  the  retroperitoneal 


ANATOMY 


259 


space.  So  much,  in  rough  outhne,  for  the  relations  of  the  pelvic 
organs,  and  their  blood  and  lymph  connections  when  viewed  from  above. 
In  approaching  the  uterus  from  below  by  the  perineal  route,  one  en- 
counters another  interesting  series  of  relations,  concerned  mainly  with 
the  supports  of  the  pelvic  floor.     The  approach  from  above  may  be 

Sup.  ves. 

Hypof^^istric 


Fig.  139.- — Relations  of  the  ureters  and  the  cervix  uteri  (Kelly). 

regarded  as  in  the  field  of  major  surg•er3^  Sometimes  the  approach  from 
below  is  regarded  as  in  the  field  of  minor  surgery.  If  one  remembers 
that  the  important  structures  in  the  pelvic  floor — the  anus,  vagina, 
and  urethra — are  passages  for  elimination,  and  that  they  form  weak 
points  at  the  bottom  of  the  abdominal  cavity,  one  will  comprehend  the 
importance  of  weaving  about  them  a  muscular  and  aponeurotic  network 


260 


FEMALE  ORGANS  OF  GENERATION 


which  shall  support  the  great  weight  of  abdominal  viscera  pressing  from 
above,  but  at  the  same  time  shall  allow  the  urethra,  vagina,  and  anus 
properly  to  functionate.  In  this  connection  it  is  interesting  to  observe 
that  much  of  the  damage  and  disease  which  occur  in  these  dependent 
regions  are  concerned,  on  the  one  hand,  with  the  breaking  down  of  the 
pelvic  floor  and  a  dropping  out  of  viscera,  and,  on  the  other  hand,  with 
obstructions  or  i)artial  closures  of  the  three  channels  of  vent. 


Fig.  140. — Distribution  of  lymphatics  of  the  uterus  (Kelly). 

So  observe  the  perineal  supports.  There  is  the  sphincter  ani,  closely 
associated  with  the  two  trans  versus  perinei  and  constrictor  vaginae 
muscles.  These  four  form  a  delicate  external  network  of  muscles,  whose 
function  it  is  to  control  and  regulate  the  outlets  of  the  anus  and  vag- 
ina. These  muscles  have  no  great  supporting  strength.  Above  them, 
however,  lies  the  true  strength  of  the  pelvic  floor,  the  levator  ani  muscle, 
the  powerful  hammock  in  which  rest  the  pelvic  viscera.  So  one  sees  that 
damage  to  the  external  layer  of  muscles  means  damage  of  dehcate  func- 


INFLAMMATIONS  261 

tion  only;  while  injury  to  the  levator  ani  muscle  results  in  serious  de- 
rangements of  the  pelvic  and  abdominal  viscera. 

Bearing  in  mind  these  important  facts, — that  in  approaching  the 
uterus  from  below  the  vagina  offers  an  ample  passage  usually  for  opera- 
tion, and  that  the  ureters  and  uterine  vessels  lie  low  in  the  pelvis,  against 
the  upper  portion  of  the  vaginal  wall, — let  us  proceed  now  to  discuss  the 
more  common  injuries  and  diseases  of  the  uterus  itself. 

We  limit  ourselves  in  this  chapter  to  the  more  serious  and  common 
lesions  of  the  uterus  with  which  the  general  surgeon  deals — with  in- 
Jiamniations,  lacerations,  disj)Iacevi€7its,  tumors. 

INFLAMMATIONS 

Inflammations  of  the  uterus  are  so  closely  associated  with  inflamma- 
tions of  other  portions  of  the  genital  tract  that  it  is  difficult  in  practice 
to  dissociate  them,  \^'e  speak  of  the  uterus  and  adnexa.  In  truth  and 
embr3^ologically,  the  tubes  and  ovaries  are  no  more  adnexa  of  the  uterus 
than  are  the  spermatic  cord  and  testes  adnexa  of  the  prostate;  but  clinic- 
ally and  conventionally  we  still  talk  of  the  uterus  and  its  adnexa.  When 
the  uterus  is  inflamed,  the  adnexa  frequently  are  involved.  Now, 
the  generative  tract  in  women  differs  from  all  other  mucous-membrane- 
lined  tracts  in  either  sex — it  is  continuous  with  a  serous  cavity;  there  is 
a  direct  communication  from  the  external  genitals  through  the  vagina, 
uterus,  and  tubes  to  the  peritoneal  cavit}".  This  fact  renders  serious 
the  inflammations  of  the  female  generative  organs,  though,  fortunately, 
inflammation  of  the  tubes  quickly  seals  their  fimbriated  ends,  so  that  an 
associated  local  peritonitis  is  generally  due  to  infection  spreading  thi'ough 
the  walls  of  the  uterus  and  tubes.  Moreover,  the  lymphatic  apparatus 
of  these  organs  is  so  complex  and  extensive  that  infections  are  quickly 
and  readily  conveyed  to  other  parts.  Their  nervous  mechanism,  too, 
is  nearly  associated  with  the  general  health  and  well-being  of  women. 
As  a  result  of  all  this  we  must  look  upon  uterine  inflammations  as  im- 
portant phenomena  whenever  and  wherever  they  appear. 

A  discussion  of  the  nomenclature  of  these  inflammations  and  their 
division  according  to  locality  and  duration  is  unsatisfactor5^  We  talk 
of  endometritis,  endocervicitis,  metritis,  and  parametritis,  and  we  divide 
these  processes  into  classes — acute,  subacute,  and  chronic.  As  a  fact, 
all  these  varieties  overlap  and  run  into  one  another,  so  that  it  is  impos- 
sible often  to  tell  with  just  what  form  we  are  dealing.  Moreover,  the 
tubes  and  ovaries  may  share;  in  the  infection,  thus  complicating  further 
the  problem  of  diagnosis  and  treatment. 

Furthermore,  in  this  discussion,  as  in  the  discussion  of  inflammations 
elsewhere,  one  should  distinguish  clearly  the  terms  infection  and  inflam- 
mation, as  Dudley  points  out.^  By  infection  we  mean  that  condition  in 
which  foreign  media  (bacteria)  invade  tissues  and  interfere  with  function. 
Inflammation  is  a  result  of  infection.  The  irritation  caused  b}"  invading 
organisms  draws  to  the  region  leukocytes,  with  a  resulting  seroplastic 

^  E.  C.  Dudley,  Principles  and  Practice  of  Gynecology,  Chapter  X. 


262 


FEMALE  OKGANS  OF  GENERATION 


infiltration,  setting  up  a  barrier  to  further  invasion.  This  barrier  is 
evidenced  by  swelling,  heat,  redness,  and  pain.  'J'hat  is  infianmiation; 
and,  conversel}',  one  observes  that  if  no  obstructing  inflaniniation  occurs, 
the  infection  may  run  an  unchecked  course  and  may  advance  rapidly 
until  it  overwhelms  and  kills  the  patient — septicemia. 

The  etiology  of  the.^e  infections  is  various.  There  are  the  predispos- 
ing causes— a  generally  lowered  vitality  from  ovenvork,  wony,  or  disease; 
and  local  causes — injury  to  any  part  of  the  genital  tract  from  pregnane}' 
or  parturition,  abortion,  improper  local  treatment,  operations,  mastur- 
bation, catheterization,  and  from  gonorrheal,  sj-philitic,  and  other  such 
infections.     Gonorrhea  is  perhaps  the  most  common  and  the  most  serious 


Fig.  141. — Uterus  from  patient  dying  on  tenth  day  from  pure  streptococcic  infection 

(Jewett). 

form  of  infection.  This  disease  attacks  and  finds  read}'  lodgment  in  the 
external  genitals  and  urethra ;  it  invades  the  vagina  with  difficulty,  but  it 
runs  riot  and  lingers  long  in  the  uterus,  especially  in  the  cervix,  with  its 
numerous  and  extensive  crypts,  tubules,  and  glands;  and  it  passes  easily 
from  the  uterus  to  the  Fallopian  tubes.  This  extension  of  infection, 
whether  bacterial  or  some  other,  travels  by  continuity  of  the  nmcosa 
and  by  the  lymphatics  and  blood-vessels. 

In  brief,  one  may  distinguish  the  ande  infections  as  those  vii-ulent 
forms  which  call  out  the  defensive  inflammatory  pi'ocesses  I  have  des- 
cribed and,  finally,  produce  local  necrosis,  with  a  termination  in  resolu- 
tion or  further  advance  to  progressive  suppuration.  At  any  time  the 
acute  infection  may  break  through  the  barrier  and  invade  the  whole 


INFLAMMATIONS 


263 


body.  Sometimes  the  acute  process  heccjmes  chronic;  its  intensity 
diminishes,  little  defensive  action  is  provoked,  so  that  instead  of  a  local- 
ized destructive  process  there  results  an  excess  of  construction.  Or  the 
disease  may  be  subacute  or  chronic  from  the  outset,  and  in  turn  may 
at  any  time  become  acute  on  due  provocation.  Let  us  discuss  briefly 
and  successively  acute  and  chronic  metritis  and  acute  and  chronic 
endometritis,  with  the  subvariety,  endocervicitis.  Parametritis  is  but 
the  beginning  of  a  pelvic  peritonitis,  which  we  shall  study  in  connection 
with  disease  of  the  tubes  and  ovaries. 

Acute  metritis,  or  inflammation  of  the  whole  of  the  womb,  is  one 
of  the  most  puzzling  and  serious  of  diseases.  The  process  begins  ordi- 
nai'il}-  in  the  endometrium,  but  extends  rapidly  through  the  lymphatics 
to  the  body  of  the  uterus  and  to  the  peritoneum  and  adjacent  struc- 
tures even.  The  causes  of  metritis  are  those  I  have  already  named,  but 
probabh'  the  most  common  cause  is  child- 
birth or  abortion,  followed  by  the  retention 
of  some  of  the  products  of  conception,  w^hich 
often  become  infected,  and  in  their  turn  in- 
fect the  uterus  itself.  The  rapid  and  fre- 
quently fatal  progress  of  acute  metritis  is  due 
to  the  close  relations  through  the  lymphatic 
channels  of  the  endometrium  and  the  uterine 
peritoneum.  Streptococci  are  the  common 
offending  organisms.  One  finds,  three  or 
four  days  after  the  beginning  of  infection, 
that  the  uterus  is  somewhat  larger  than  it 
should  be,  smooth  in  outline,  and  doughy 
or  soft.  There  is  an  extreme  congestion, 
wdth  bloody  extravasation  in  the  walls  of 
the  organ.  The  endometrium  and  para- 
metrium are  deeply  engorged,  and  there  is 
an  abundant  small-cell  infiltration  of  all  the 
tissues  concerned.  The  lymph-vessels  are 
distended,  and  the  uterine  glands  secrete  a 
copious   fluid.      The    extent    of    all    these 

changes  depends,  of  course,  on  the  virulence  of  the  infection  and  the 
abihty  of  the  organism  to  set  up  a  protective  barrier.  Abscesses  seldom 
form  in  the  uterine  wall  unless  there  be  complicating  m}'omata. 

The  symptoms  are  often  grave,  though  they  may  be  insidious  and 
take  weeks  in  development.  The  patient  looks  sick,  and  frequenth^  has 
that  peritoneal  facies  with  which  we  are  familiar.  The  temperature 
runs  up,  and  fluctuates  in  a  typhoidal  fashion.  There  may  be  an  initial 
chill.  There  is  general  abdominal  discomfort,  often  associated  with 
pain  above  the  pubes,  radiating  to  the  back  and  thighs.  Movements  of 
the  bowels  are  painful,  and  rectal  tenesmus  is  common;  the  passage  of 
urine  is  frequent  and  painful,  because  there  is  often  an  associated  cystitis. 
Often,  too,  the  patient  complains  bitterly  of  nausea,  vomiting,  and  con- 
stipation.    If  the  uterine  inflammation  persists  through  the  time  of  a 


Fig. 


142.— Uterus     dilated. 
Acute  metritis. 


264  FEMALE  ORGANS  OF  GENERATION 

menstrual  period,  the  flow  may  be  suppressed,  though  occasionally, 
when  myoniata  are  present,  there  may  be  a  jjersistent  and  even  danger- 
ous hemorrhage.  The  flow  consists  of  changed  and  clotted  blood,  mixed 
with  the  uterine  secretions.  Sometimes  the  laboring  organ  attempts 
to  express  clots  and  other  collections,  with  the  result  that  a  pain  or 
pains,  like  exaggerated  labor-pains,  ensue.  If  the  inflammation  ex- 
tends to  the  adnexa,  the  pelvic  connective  tissue,  and  especially  the 
peritoneum,  we  shall  find,  in  addition,  those  severe  and  alarming 
symptoms  of  peritonitis  which  we  have  already  studied  (Chapter  VIII). 
If  unchecked  and  unopposed,  the  disease  goes  on  to  death  by  septicemia. 

We  make  our  diagnosis  by  observing  the  symptoms  and  by  finding 
such  phvsical  signs  as  tenderness  o\'er  the  pubes,  in  the  inguinal  regions, 
and  in  the  vagina;  tense  abdominal  walls ;^  a  vagina  hot  to  the  touch;  an 
abnormal  uterine  discharge,  and  an  enlarged  and  softened  uterus.  It 
may  seem  best  to  examine  through  the  speculum  the  condition  of  the 
cervix  and  os,  but  probing  of  the  uterine  canal  is  dangerous  and  profit- 
less. 

The  treatment  of  this  alarming  form  of  inflammation  rarely  is  imme- 
diately obvious,  and  calls  for  the  coolest  and  most  patient  judgment. 
Some  of  the  gravest  cases  recover  under  palliative  measures,  while 
not  infrequently  cases  mild  at  the  outset  go  on  to  the  severest  complica- 
tions and  to  death.  In  the  face  of  no  form  of  disease  does  one  so  fre- 
quently meet  with  so  great  a  divergence  of  opinions  among  consulting 
surgeons  in  an}'  given  case.  Writers  talk  about  abortive  treatment, 
palliative  treatment,  and  expectant  treatment.  These  are  forms  of 
treatment  applicable  in  the  early  stages  only,  or  else  late,  when  any 
radical  operation  obviously  would  be  fatal.  The  milder  forms  of  treat- 
ment consist  of  absolute  rest  in  bed,  frequently  changed  hot  poultices  - 
upon  the  abdomen  (I  use  creolin  poultices,  1  :  200.  and  find  the  slight 
sting  of  the  creolin  grateful  to  many  patients).  Sometimes  leeches  to 
the  cervix  are  effective,  and  leeches  to  the  peiineum  and  inguinal  regions. 
Move  the  bowels  thoroughly  with  calomel.  The  treatment  may  be 
carried  further  by  giving  small  doses  of  opium  for  pain  and  hot  lysol 
douches.  .  In  all  cases  cultures  of  the  discharge  should  be  made  and  the 
appropriate  vaccines  injected. 

Such  simple  means  are  easy  of  application,  but  the  strain  upon  the 
physician's  resources  is  far  greater  than  the  limits  of  palliative  thera- 
peutics. He  is  face  to  face  with  a  great  problem,  with  which  an  indo- 
lent or  an  ignorant  man  only  can  rest  easy.  The  intelligent  practitioner 
must  be  agitated  by  the  thought  of  the  importance  of  active  surgical 
intervention.  Three  questions  should  be  uppermost  in  his  mind:  Is 
the  source  of  this  infection  some  focus  of  decomposition  in  the  uterus — 
some  disorganized  products  of  conception?  Or  is  the  uterine  mucosa 
the  seat  of  infection — possibly  a  gonorrhea?  Or  has  the  disease  spread 
and  involved  deeper  tissues?  Is  the  peritoneum  involved,  and  are  there 
infections  of  distant  organs? 

1  As  in  other  forms  of  peritonitis,  the  walls  may  be  lax. 

2  The  local  induced  anemia  due  to  cold  (ice-bag)  is  often  extremely  effective. 


INFLAMMATIONS 


265 


These  are  far-reaching  problems,  each  one  of  which  might  be  made 
the  subject  of  a  chapter.  Briefly,  if  there  has  been  recently  an  abortion 
or  hxbor  at  term ;  if,  after  two  clays,  the  patient's  temperature  begins  to 
run  up ;  if  tenderness  over  the  uterus  increases  and  the  other  signs  and 
symptoms  of  infection  appear,  we  have  evidence  of  an  intra-uterine 
irritation  which  must  be  removed.  Not  to  encroach  too  much  upon  the 
literature  of  obstetrics,  suffice  it  to  say  that  cureting  will  eliminate 
the  offending  mass  and  relieve  the  symptoms.  This  is  the  case  and  the 
only  case  in  which  one  may  use  the  dull  wire  curet  or  the  finger  armed 
with  rubber  glove.  You  will  find  little  difficulty  in  this  simple  oper- 
ation. The  patient  should  be  draw^n  to  the  edge  of  the  bed,  or  prefer- 
ably placed  upon  a  table  and  in  the  lithotomy  position.     The  greatest 


Fig.  143. — Position  for  curetage  of  uterus. 

antiseptic  care  should  be  employed  by  shaving  the  external  parts,  scrub- 
bing them  with  soap  and  water,  and  douching  thoroughly  the  vagina 
with  lysol  (1  :  100)  and  sterile  water.  Often  an  anesthetic  is  needless. 
The  OS  uteri  is  generally  patulous,  and  admits  readily  a  curet  of  fair  size. 
Besides  the  dull  wire  curet  a  phable  douche-curet  is  a  useful  implement. 
The  surgeon  hoes  out  carefully  the  whole  interior  of  the  uterus,  and  fol- 
lows this  procedure  by  a  copious  intra-uterine  douche  of  sterile  water. 
Further  intra-uterine  medication  is  needless.  If  this  operation  is 
done  properly  and  thoroughly,  the  patient  will  at  once  return  to  the 
normal. 

In  a  few  rare  and  unfortunate  cases,  however,  extensive  involve- 
ment of  the  uterine  wall  and  surrounding  tissues  has  already  taken  place, 


266  FEMALE  ORGANS  OF  GEXEKATION 

and  the  process  will  not  be  checked  by  curetage.  Here  is  one  of  the 
most  trying  and  difficult  of  emergencies.  The  surgeon  must  approach 
it  from  a  point  of  view  similar  to  that  from  which  he  approaches  a  diffuse 
peritonitis  from  appendicitis.  An  active,  septic  focus  is  present,  and 
that  focus  must  be  removed.  Here  again,  one  is  governed  by  the  con- 
ditions which  he  finds.  If  there  be  an  inflammation  limited  to  the  pelvis 
and  involving  the  para-uterine  tissues  and  adnexa  only, — j)ossil)ly  with 
an  abscess  pointing  in  the  vagina, — it  will  suffice  to  incise  the  pouch  of 
Douglas  and  drain  the  products  of  inflammation.  In  rare  and  desperate 
cases  it  may  be  necessary  to  open  the  abdomen  and  remove  the  uterus 
with  its  appendages.  This  should  not  be  done  in  the  face  of  impending 
death,  and  at  the  best  or  woi-st  it  is  a  desperate  remedy.  After  such  an 
operation,  which  should  involve  a  minimum  of  disturbance  to  the  intes- 
tines (pro\-ided  for  by  the  use  of  a  modified  Trendelenburg  position),  the 
surgeon  should  wipe  out  carefully  the  pelvis,  and  drain  it  through  rubber 
drainage-tubes— one  above  the  pulses  and  ninning  to  the  bottom  of  the 
pelvis,  one  in  the  vagina,  draining  Douglas's  pouch.  Fuilhermore,  there 
is  a  great  advantage  aftei-ward  in  placing  the  patient  in  Fowler's  posi- 
tion, and  for  the  first  twelve  to  twentj'-four  hours  employing  the  seeping 
enemata  described  in  our  chapter  on  Peritonitis  (Chapter  VIII). 

Those  cases  of  metritis  due  to  other  infections  (gonorrhea,  etc.), 
invoh-ing  the  uterine  mucosa  call  for  a  somewhat  different  course  of 
surgical  treatment.  Generally  thej'  are  less  urgent  and  alarming  than 
the  puerperal  cases,  but  many  times  the}'  progress  to  the  same  fatal 
termination.  If  palliative  measures  fail,  the  next  step  is  curetage — 
curetage  of  a  more  radical  nature  than  that  described  in  a  previous  para- 
graph. The  dull  curet  is  worse  than  useless  here.  One  must  give  the 
endometrium  a  thorough  scraping  with  a  shaip  spoon-curet,  going  over 
the  whole  interior  of  the  organ  in  painstaking  fashion,  and  being  satis- 
fied only  when  the  curet  conveys  to  the  hand  the  characteristic  grating 
feel,  as  though  being  dra^Mi  over  sound  tissue.  The  separated  lining 
membrane  is  discharged  through  the  cervix  by  uterine  contractions, 
assisted  by  the  curet.  As  a  preliminary  to  cureting.  the  cervix  must 
be  dilated — not  dilated  violently  and  suddenly  with  the  ratchet  instm- 
ments  in  common  use,  but  gradually;  and  I  recommend  the  careful  em- 
plo3'ment  of  the  Hanks  and  Goodell-Ellinger  dilators. 

Fortunately,  acute  metritis  of  this  form  is  a  rare  affection,  but  in 
case  it  extends  further  and  threatens  continued  progress,  one  may  be 
forced  again  to  the  radical  operation  of  abdominal  hysterectomy. 

In  case  we  have  to  answer  affirmatively  our  third  question — that  is, 
in  case  there  be  a  general  systemic  infection,  treatment  of  local  condi- 
tions may  be  of  little  avail.  One  should  see  to  it,  however,  that  abund- 
ant pelvic  drainage  is  instituted,  if  possible,  through  the  vagina;  and 
one  should  endeavor  to  combat  the  general  infection  by  such  supporting 
measures  as  giving  whisky  and  strychnin,  with  forced  feeding  and  the 
injection,  intravenously,  of  normal  salt  solution.  Above  all  things, 
open-air  treatment  is  essential.  I  have  seen  more  than  one  patient  who 
had  dragged  along  for  weeks  when  confined  to  the  house  recover  rapidly 


INFLAMMATIONS 


267 


and  completely  upon  being  sent  out-of-doors  to  live  on  the  i)iazza  or  in  a 
tent.     The  propel-  oj)sonin8  also  will  hasten  convalescence. 

Chronic  metritis  is  properly  an  infianimation  of  tlu;  uterine  muscle, 
and  should  be  called  more  accurately  myometritis.     Like  acute  metritis, 
it  starts  usually  in  the  endometrium  and  can- 
not readil}-  be  distinguished  sharph'  from  endo- 
metritis.   Sometimes  the  term,  chronic  metritis, 
does  not  imply  a  definite  infective  process,  but 
implies  certain  chronic  changes  in  the  quantity 
and  quality  of  the  glandular  elements,  muscu- 
laris,  blood-vessels,  lymphatics,  and  connective 
tissue.      ]\lan3'  of  these   cases,   therefore,   are 
non-infective  in  origin,  and  Fothergill  ^  points 
to  the  investigations  of  Theilhaber,  Meier,  and 
Donald  as  proving  the  ex- 
istence of  a  non-inflamma- 
tory condition  in  which  the 
symptoms    are    discomfort, 
menorrhagia,     and    leukor- 
rhea,     while    the     obvious 
pathologic  feature  is  hj^per- 
trophy  of  the  uterine  mu- 
cosa.    Certainly  it  appears 


Fig.  14-1.— The  dilating  ends  of  Fig.  145. — Hanks           Fig.  146.— Goodell-El- 

the  three  sizes  of  the  Ellinger  and  dilator.              linger  dilator  with  spring 

Goodell-Elhnger    dilators    (natural  between  the  handles,  but 

size),  showing  a  slight  curve  and  the  without  a  ratchet, 
relative  sizes  (Kelly). 

that  the  uterine  muscle  probably  plays  a  more  important  part  in  the 

causation  of  common  pelvic  disorders  than  hitherto  has  been  recognized. 

So  we  may  have  an  infective  chronic  metritis  and  a  non-infective  chronic 

^  Practitioner,  March,  1904. 


268 


FEMALE  ORGANS  OF  GENERATION 


metritis,  with  quite  similar  appearances.  One  finds  the  utems  to  be 
enlarged  symmetrically,  harder  and  firmer  than  normal.  Later,  atrophic 
changes  may  cause  a  shrinking  of  the  organ  to  less  than  normal  size. 
There  is  little  tenderness  on  pressure,  and  there  is  not  often  an  involve- 
ment of  the  appendages.  The  uterus  maj'  or  may  not  be  movable, 
and  it  may  or  may  not  be  displaced,  but  enlargement  of  the  cavity  is 
demonstrable  by  the  use  of  the  sound. 

Furthermore,  chronic  metritis  must  be  distinguished  from  subinvolu- 
tion, in  which  the  uterus  is  large,  often  rather  hard  and  insensitive,  and 
subject  to  frequent  and  considerable  hemorrhages. 

The  symptoms  of  chronic  metritis  are  elusive  often.  There  is  rarely 
fever,  nor  is  there  acute  pain,  but  there  is  a  sense  of  aching,  pressure, 
weight,  and  dragging  in  the  back,  hj'pogastrium,  and  thighs.  There  are 
frequent  hemorrhages.  Dysmenorrhea  often  is  present.  Such  patients 
are  usually  sterile.  Actions  of  the  bowels  and  bladder  are  painful, 
and  the  patient  suffers  from  all  sorts  of  reflex  symptoms — dyspepsia, 
headache,  blurring  of  vision,  and  insomnia,  resulting  in  malnutrition 
and  chronic  invalidism. 

The  differential  diagnosis  is  correspondingly  difficult.  I  take  the 
following  instructive  table  from  Dudley's  book: 


Chroxic  Metritis. 

Menorrhagia  and  inter- 
menstrual uterine 
hemorrhages  not  in- 
variable. 

Xo  signs  of  pregnancy. 


Small  Fibroid  Tumors. 

1.  Menorrhagia  and  uter- 

ine   hemorrhage    the 
rule. 

2.  Xo  signs  of  pregnancy. 


3.  Uterus  hard  and  regular     3.  Uterus  hard  and  irregu- 
in  outline.  lar  in  outhne. 


Uterus    commonly     in     4. 
pathologic  anteversion 
and  descent;   may  be 
in  retroversion. 


Uterus  liable  to  be  dis- 
placed in  any  direc- 
tion according  to  the 
mechanical  influence 
of  the   fibroids. 


Early  Pregnancy. 
1.  Amenorrhea. 


2 .  Signs  of  early  pregnancy : 

(a)  Morning  sickness. 

(b)  Breasts  enlarged. 

(c)  Blue    discoloration  of 
vaginal  mucosa. 

(d)  Softening  of  the  cerA'ix 

uteri. 

3.  Uterus  soft  and  regular 

in  outline;  may  mo- 
mentarily contract 
and  harden  on  hand- 
hng. 

4.  Uterus  commonly  ante- 

verted. 


The  treatment  of  chronic  metritis  in  its  elaboration  falls  properly  to 
the  gynecologist,  who  must  consider  the  associated  lesions — endometri- 
tis, parametritis,  etc.  Not  infrequently  one  must  resort  to  removal  of 
the  utems,  and  for  this  operation  the  general  surgeon  should  be  prepared. 
While  the  abdomen  is  open,  remove  the  appendix  vermiformis.  I  am 
convinced,  in  spite  of  ancient  prejudice,  that  the  appendix  should  al- 
ways be  removed  whenever  the  abdomen  is  opened  for  operation  upon 
organs  in  its  neighborhood. 

Acute  endometritis  cannot  well  be  distinguished  from  the  general 
acute  metritis  I  have  described,  but  chronic  endometritis  is  distinguish- 


INFLAMMATIONS 


269 


able  as  a  separate  process,  limited  to  the  endometrium;  and  chronic 
endocervicitis  or  cervical  endometritis  is  a  special  form  or  subdivision  of 
endometritis.  The  interior  of  the  cervix  is  cut  off  by  the  internal  os 
from  the  rest  of  the  endometrium.  The  cervical  portion  especially  is 
subject  to  infection — more  so  than  the  deeper  and  better  guarded  endo- 
metrium proper.  The  numerous  glands  of  the  cervix  are  a  ready  culture 
ground  for  invading  organisms,  and  the  infection  commonly  spreads  to 
them  from  without — especially  gonorrhea;  or  is  set  up  from  an  infected 
puerperal  laceration,  from  foreign  bodies,  tumors,  or  polypi,  or  from  un- 
clean instruments  and  fingers.  The  ordinary  phenomena  of  a  catarrh 
appear — engorgement,   thickening,   exudation,   followed  especially  by 


Fig.  147. — Erosion  of  the  cervix  (Cullen). 

so-called  erosion  of  the  epithelium — properly  a  hypertrophy  of  papillse 
and  a  condition  of  chronic  ulceration,  with  a  rolling  out  of  the  cervical 
mucosa.  In  multiparse  the  engorgement  sometimes  blocks  completely 
the  external  os  and  results  in  retention  of  the  secretions,  with  dilatation 
of  the  cervical  canal.  Erosions  and  glandular  enlargements  are  the  con- 
spicuous features  of  cervical  endometritis,  and  from  the  latter  there  may 
result  the  development  of  mucous  potypi  and  that  form  of  cystic  glandu- 
lar enlargement  with  the  formation  of  retention  cysts  known  as  ovula 
Nabothi. 

The  symptoms  of  endocervicitis  are  irregular  and  not  characteristic. 
Such  symptoms  as  these  are  may  be  due  to  compHcations,  or  there  may 


270 


FEMALE  ORGANS  OF  GENERATION 


be  no  symptoms.  Commonly  we  look  for  irregular  and  painful  menstrua- 
tion, sterility,  })ain  in  the  rejiion  of  the  coccyx,  a  sense  of  weight  in  the 
pelvis,  and  suntlry  remote  functional  disorders- — neuroses  antl  th'spepsia. 
In  the  case  of  polypi  there  may  be  hemorrhages — frequent  and  some- 


a  b 

Fig.  148. — Schroder's  operation:  a,  Showing  a  thickened,  diseased  cer\'ix 
requiring  resection.  Tlie  dotted  lines  show  where  the  incisions  should  be  made,  b, 
Diseased  tissues  excised.  Sutures  in  place  for  the  union  of  the  vaginal  to  the  intra- 
uterine margins  of  the  wound,  but  not  yet  tied. 

times  alarming,  especially  tluring  the  menstrual  period.     The  diagnosis 
is  based  on  a  careful  vaginal  examination  w^ith  the  speculum. 

The  treatment  of  endocervicitis  is  toj^ical  and  operative.  It  is  by  no 
means  possible  always  to  cure  it  by  applications,  and  often  when  the 


Fig.  149. — Schroder's  operation:  a,  Vaginal  margins  sutured  to  the  intra-uterine 
margins  of  the  wound.  Lateral  surfaces  denuded  and  passed,  but  not  yet  tied,  b, 
Lateral  sutures  introduced  for  the  comj^letion  of  the  ojieration,  and  tied.  The  white 
dots  in  the  os  externum  represent  the  ends  of  the  protruding  .sutures,  which  are 
now  rolled  far  into  the  cervical  canal. 


irritation  persists  one  must  perform  a  somewhat  radical  operation — 
removal  of  the  affected  area.  In  my  opinion  the  best  of  these  operations 
is  that  of  Schroder.  The  sketches  illustrate  this  procedure — the  re- 
moval of  tis.sue  and  the  .sewing  up  of  the  exposed  raw  surfaces. 


INFLAMMATIONS  271 

If  there  are  polypi,  they  must  be  twisted  off  after  the  external  os 
has  been  dilated;  and  in  the  case  of  obstruction  with  distention  of  the 
canal,  an  operation  similar  to  that  of  Schroder  gives  the  best  result. 
Little  is  gained  by  dilatation  alone,  or  by  scoring  of  the  cervix  without 
removal  of  tissue,  for  after  such  treatment  recontraction  of  the  os  is 
almost  sure  to  take  place. 

Endometritis  of  the  body  of  the  uterus  presents  a  problem  of 
greater  difficulty  than  the  subvariety,  endocervicitis,  which  I  have 
just  considered,  if,  indeed,  we  can  make  a  clear  distinction  between  en- 
dometritis and  endocer\dcitis.  We  recognize  glandular  endometritis, 
interstitial  endometritis,  and  a  combination  of  glandular  and  interstitial 
endometritis.  These  forms  present  the  appearances  which  their  names 
indicate,  and  are  characterized  by  enlargement  of  the  uterine  glands, 
sometimes  by  their  multiplicity  (occasionally  designated  benign  adeno- 
ma), by  great  increase  of  connective  tissue  in  the  endometrium  at  the 
expense  of  the  glandular  elements,  or  by  a  combination  of  all  these  con- 
ditions, wliich  may  result  in  the  formation  of  polypi.  Gynecologists 
describe  six  clinical  forms  of  endometritis — post -abortion  endometritis, 
exfoliative  endometritis,  senile  endometritis,  tuberculous  endometritis, 
decidual  endometritis,  and  septic  endometritis;  and  in  making  the  diag- 
nosis we  look  for  much  the  same  symptoms  as  in  the  case  of  cervical  endo- 
metritis: menstrual  and  intermenstrual  disturbances,  excessive  mucous 
discharges,  hemorrhages,  sterility,  dragging  sensations  in  the  pehas, 
tympany,  pain  in  the  epigastrium,  and  vesical  and  rectal  tenesmus. 
To  confirm  the  diagnosis  one  should  always  depend  upon  a  microscopic 
examination  of  scrapings  from  the  endometrium,  and  this  is  extremely 
important  in  view  of  the  possibility  of  cancer  developing  in  the  same 
organ.  Moreover,  a  discharge  supposed  to  come  from  the  endometrium 
may  have  its  origin  in  the  Fallopian  tubes. 

The  outlook  for  long-estabHshed  cases  of  endometritis  is  not  encourag- 
ing, and  after  apparent  cure  even  relapses  are  common.  The  mildly 
infected  cases  yield  readity  to  general  treatment  ^tonics,  change  of  air, 
etc.;  but  the  more  serious  cases  always  require  a  surgical  operation,  and 
at  the  best  the  prognosis  is  discouraging  in  exfoliative,  senile,  and  tuber- 
culous endometritis. 

The  treatment  of  chronic  endometritis  may  be  discussed  conveniently 
under  three  headings:  (a)  Systemic  treatment;  (6)  topical  treatment; 
(c)  surgical  treatment. 

Those  cases  which  mothers  and  old-fashioned  persons  refer  to  as  "  a 
female  weakness  "  belong  often  to  the  class  requiring  systemic  treatment, 
and  I  have  already  referred  to  the  course  of  such  treatment.  The  sur- 
geon must  inciuireinto  the  patient's  general  condition,  he  must  combat 
anemia,  rheumatism,  constitutional  syphilis,  diabetes,  renal  and  cardiac 
disease,  and  chronic  constipation  by  appropriate  measures;  and,  above 
all,  he  must  place  the  patient  in  the  most  favorable  hygienic  surroundings. 

Topical  treatment  is  sometimes  useful,  but  its  value  has  been  greatly 
exaggerated,  just  as  the  value  of  systemic  treatment  has  been  neglected. 
Unfortunately,  as  Dudley  points  out,  applications  which  have  the  power 


272  FEMALE  ORGANS  OF  GENERATION 

to  destroy  disease  may  destroy  the  endometrium,  injure  the  myometrium, 
and  reduce  the  uterus  to  a  cirrhotic,  cicatricial  condition,  with  steriHty 
and  permanent  irritabiUty  of  all  the  j^elvic  organs  as  a  result.  This  is 
not  the  phice  to  discuss  the  infinite  varieties  of  topical  treatment;  for 
that  discussion  I  refer  the  reader  to  the  text-books  on  Gynecology. 

Surgical  treatment  concerns  us  especially,  and  the  leading  factor  in 
surgical  treatment  is  curetage,  with  thorough  dilatation  of  the  canal  and 
irrigation,  as  I  have  already  described  them  in  this  chapter.  Some- 
times, in  the  case  of  long-standing  obstinate  disease,  it  is  well  to  apply  to 
the  endometrium,  after  curetage,  a  saturated  solution  of  iodin  crystals 
in  95  per  cent,  carbolic  acid.  I  do  not  regard  the  gauze  tampon  as  a 
necessary  dressing.  Good  results  are  obtained  without  it  because  the 
natural  drainage  of  the  uterus  after  dilatation  is  excellent. 

In  spite  of  all  such  measures,  however,  permanent  repair  of  the  dam- 
aged uterus  may  be  impossible,  especially  when  the  endometritis  is 
comphcated  with  such  extensive  disease  as  I  described  in  discussing 
metritis.  In  that  case  curetage  is  not  even  palliative,  and  the  best  hope 
of  comfortable  life  for  the  patient  lies  in  a  supravaginal  hysterectomy. 

LACERATIONS 

Lacerations  of  the  uterus  are  due  to  parturition  commonly.  Every 
woman  who  has  been  pregnant  is  the  subject  of  some  laceration  of  the 
cervix.  The  fundus  uteri  may  be  ruptured  by  a  fall  or  blow;  it  may  be 
pierced  by  a  curet  or  sound ;  it  may  burst  during  labor  even,  and  sundry 
rare  and  curious  accidents  may  befall  any  portion  of  the  uterus,  but  the 
ordinary  lacerations  of  the  uterus  are  labor  tears  of  the  cervix.  Gen- 
eral practitioners  and  general  surgeons  constantly  see  these  cases,  and 
not  many  years  ago  our  advice  to  all  patients  so  affected  was  that  they 
have  the  laceration  repaired.  There  was  a  furore  for  such  work.  We 
have  now  come  to  see  that  a  laceration  of  the  cervix  does  not  necessarily 
cause  distressing  symptoms  or  invalidism.  Many  a  deeply  torn  cervix 
in  a  healthy  woman  may  be  carried  through  a  long  life  without  her 
knowledge  of  the  injury. 

When  symptoms  are  present,  they  may  vary  all  the  way  from  the 
discomfort  of  a  cervical  catarrh  to  a  condition  of  frequent  miscarriage 
or  confirmed  invalidism,  with  constant  backache,  dysmenorrhea,  ster- 
ility even,  and  pronounced  neurasthenia.  Moreover,  we  feel  confident 
that  these  tears,  long  neglected,  and  in  a  state  of  chronic  irritation, 
frequently  become  the  site  of  malignant  disease.  (I  make  this  state- 
ment with  a  full  knowledge  of  the  assertion  of  certain  surgeons  that 
cervical  lacerations  do  not  enter  into  the  etiology  of  uterine  cancer.) 
Lacerations  may  take  place  at  any  portion  of  the  cervical  outlet, 
but  the  anterior  and  posterior  tears  heal  so  promptly  that  they  are 
rarely  observed  by  the  physician.  Lateral  tears  do  not  so  heal.  These 
are  the  tears  which  cause  trouble,  and  the  trouble  is  due  directly  to 
secondary  causes — to  infection,  endocervicitis,  and  glandular  enlarge- 
ments and  "erosions,"  so  called,  which  are  really  poutings  of  the  engorged 


LACERATIONS 


273 


cervical  mucosa.  Such  an  inflamed  and  irritated  cervix  rarely  can  be 
cured  without  operation,  while  it  is  essential  to  bear  in  mind  that  the 
deep,  thick  cicatrices  at  the  bottom  of  these  tears  prevent  a  proper  falling 
together  of  the  everted  lips.  Before  operating  by  trachelorrhaphy  the 
surgeon  should  see  to  it  that  the  inflammation  be  in  some  measure  sub- 
dued and  the  engorgement  relieved  so  far  as  possible,  for  this  relief  will 
promote  a  more  ready  and  a  firmer  healing.  If  practicable,  the  patient 
should  be  put  to  bed  for  two  or  three  weeks  and  treated  by  hot  vaginal 
douches;  regulation  of  the  bowels,  puncture  of  the  follicles,  and  scarifica- 
tion of  the  cervix  so  as  to  draw  out  a  half-ounce  of  blood  every  four  or 
five  days  if  the  patient  can  bear  it. 

Operation. — It  is  within  the  last  thirty-five  years  only  that  the  sig- 
nificance of  cervical  lacerations  has  been  appreciated  and  their  rational 
cure  undertaken.     We  owe  the  operation  to  T.  A.  Emmet.^ 


Fig.  150.- — Bilateral  laceration  of  the 
cervix,  with  puffy,  infiltrated  hps  (H.  A. 
KeUy). 


Fig.  1.11.— Incisions  into  the  angles 
of  the  laceration  extending  down  through 
the  scar  tissue  (H.  A.  Kelly). 


After  a  careful  antiseptic  preparation,  with  shaving  of  the  parts,  the 
patient  is  put  in  the  Sims'  or  the  lithotomy  position.  I  cannot  see  that 
the  question  of  position  is  especially  important.  Before  proceeding  to 
the  repair  proper  it  is  wise,  generally,  thoroughly  to  dilate  and  curet  the 
interior  of  the  utems  if  there  be  evidence  of  inflammation.  B}'  this 
maneuver  subsequent  soiling  and  infection  of  the  fresh  wound  is  the  bet- 
ter pro^'ided  against.  In  operating  seize  the  posterior  lip  of  the  cervix 
with  bullet  forceps,  draw  it  down,  and  excise  thoroughly  the  deep  cica- 
trices on  either  side.  Then,  with  scissors  or  knife,  remove  the  diseased 
surface,  exposing  on  either  side  of  the  os  an  elliptic  wound  with  free, 
raw  bleeding  surface,  as  shown  in  Fig.  152.  Denude  from  below^  up- 
ward, as  in  this  w'ay  the  blood  wdU  not  cover  the  operation  field  as  you 

1  T.  A.  Emmet,  Surgery-  of  the  Cervix  Uteri,  Amer.  Jour.  Obstet.,  Februarv^,  1869. 
Laceration  of  the  Cer\-ix  Uteri  as  a  Frequent  and  Unrecognized  Cause  of  Disease, 
ibid.,  November,  1874.  The  Proper  Treatment  of  Laceration  of  the  Cer\-ix,  Amer. 
Practitioner,  January,  1877.  Principles  and  Practice  of  Gynecology,  Philadelphia, 
1884,  p.  466. 

18 


274 


FEMALE  ORGANS  OF  GENERATION 


bearing  on  this  matter. 


advance.  Having  denuded  thoroughly  on  both  sides  of  the  os,  leaving 
a  broad  strip  of  mucosa  between  the  two  wounds  to  form  the  new  canal, 
grasp  the  anterior  and  posterior  lips  and  bring  them  together  before  sutur- 
ing, in  order  to  make  sure  that  a  perfect  ai)pro.\imation  will  be  attained. 
Then  pass  the  sutures.  There  has  l)een  much  debate  regarding  the  nature 
of  the  suture  material  to  be  used,  because  a  prompt  union  is  essential 
to  success,  and  the  nature  of  the  suture  is  thought  to  have  an  important 
Silver  wire,  silkworm-gut,  and  catgut  have  their 
advocates.  For  some  years  I 
have  employed,  with  great 
satisfaction,  catgut  buried 
within  the  wounds.  By  this 
means  the  denuded  lips  are 
V         '"^Z  '  brought  firmly  together,  save 

^    ^jy.,  Jl  ,  fij^J^       ^-^        for  a  thin  border  of  mucosa  at 
>^^Bh\k^ji  /■K^ofei?=^^^  their    edges.       This    mucous 

border  may  be  secured  later 


Fig.  152. — Sutures,  two  buried  (after  H.  A. 
Kelly). 


Fig.  153. — The  cervix  after  all  the 
sutures  are  tied  on  both  sides  (H.  A. 
Kelly). 


by  a  few  superficial  catgut  stitches  which  cannot  interfere  with  healing 
in  the  depths  of  the  wounds.  As  a  result  of  this  operation  j-ou  will 
secure  a  normal,  well-formed  cervix  of  proper  length. 

A  light  gauze  sponge  is  left  in  the  vagina  for  twenty-four  hours  to 
absorb  discharges,  and  the  patient  is  kept  in  bed  for  ten  days.  If  dis- 
charge persist  during  convalescence,  it  indicates  usually  a  continuance 
of  endometritis,  and  suggests  the  possibility  of  a  breakdown  of  the  wound 
edges.  In  case  of  such  a  discharge,  therefore,  it  is  well  to  douche  out 
the  vagina  daily  with  a  weak  solution  of  lysol  or  plain  boiled  water. 


WOUNDS 


Wounds  of  the  body  of  the  uterus  are  most  commonly  caused  by 
instruments;  furthermore,  the  pregnant  uterus  may  be  ruptured  by  a 
blow  or  may  be  crushed,  just  as  the  intestines  or  liver  may  be  ruptured. 
Such  a  uterine  rupture  is  followed  immediately  by  a  train  of  alarming 


DISPLACEMF^NTS  275 

sj'inptonis:  by  hcnioi-rhagc,  collapse,  and,  if  the  patient  survive,  by  peri- 
tonitis. As  soon  as  the  accident  is  discovered,  the  surgeon  should  open 
the  abdomen,  remove  the  fetus,  and  clean  out  and  repair  the  injured 
uterus.     He  should  treat  peritonitis  by  the  methods  already  described. 

Perfoiation  of  the  uterus  by  a  sound,  curet,  or  other  instrument  is  a 
common  accident.  If  reasonably  careful,  you  will  not  thus  perforate  the 
normal,  healthy  uterus,  but  in  the  case  of  an  organ  septic  or  weakened 
by  disease  or  pregnancy,  it  is  easy  to  pass  an  instrument  through  the 
uterine  wall  into  the  abdominal  cavity.  Most  surgeons  have  had  such 
experiences,  and  the  sensation,  as  the  instrument  suddenly  sinks  to  its 
handle  in  a  supposedly  small  uterus,  is  extremely  alarming,  As  a  rule, 
however,  such  an  accident  is  followed  by  no  ill  effects  if  the  instrument  is 
a  clean  one.  I  have  myself  thus  perforated  the  utems,  and  have  seen 
it  so  perforated  by  others. 

Do  not  hastily  open  the  abdomen  to  repair  the  damage.  In  the 
great  majority  of  cases  a  minute  hole  only  is  made  in  the  uterus,  and  the 
wound  heals  promptly  if  let  alone.  Therefore,  let  it  alone.  Keep  the 
patient  quiet  on  her  back  for  a  week,  when  all  danger  will  have  passed. 
Rarely  a  septic  peritonitis  follows  the  accident,  and  in  that  case  the 
surgeon  must  open  the  abdomen  and  drain  it  according  to  the  recog- 
nized rules. 

DISPLACEMENTS 

Displacements  of  the  uterus  are  as  common  or  commoner  than 
lacerations.  One  finds  them  in  women  who  have  never  borne  children, 
as  well  as  in  mothers  of  families  and  at  all  ages.  Our  chapter  on  Ab- 
dominal Ptosis  (Chapter  IX)  hints  at  one  of  the  causes  of  displacements 
— a  general  relaxation  of  the  visceral  supports.  This  applies  to  all 
classes  of  women,  but  there  are  other  special  causes  for  uterine  dis- 
placements in  the  case  of  women  who  have  borne  children. 

Recall  the  anatomy  of  the  uterine  supports.  The  arrangements 
are  extremely  complicated.  We  were  wont  to  think  that  the  round 
ligaments  and  the  perineum  were  the  only  structures  concerned  in 
holding  the  uterus  in  place.  They  are  important  parts,  merely,  of  a 
complex  mechanism.  They  alone  are  quite  insufficient  for  the  work. 
As  with  all  other  abdominal  organs,  the  correct  placing  and  securing 
of  the  uterus  depends  primarily  upon  the  proper  tonicity  and  normal 
relationship  of  surrounding  organs.  The  natural  position  of  the  uterus  is 
one  of  anteversion,  when  the  rectum  and  bladder  are  empty.  It  moves 
backward  and  forward  as  those  organs  contract  and  expand.  The  uterine 
ligaments  are  all  relaxed  normally;  they  do  not  fix  the  uterus.  Excessive 
backward  displacement  of  the  fundus  is  checked  by  the  round  ligaments 
and  the  vesicovaginal  wall.  Forward  and  downward  displacements 
are  controlled  by  the  uterosacral  ligaments,  and  lateral  displacements 
by  the  broad  ligaments.  The  pelvic  floor  has  those  muscles  I  have  des- 
cribed, and  contains  structures  divided  into  pubic  and  sacral  segments. 
The  pubic  segment  includes  bladder,  urethra,  anterior  vaginal  wall,  and 
bladder  peritoneum.    The  sacral  segment  includes  the  rectum,  perineum, 


276 


FEMALE  ORGANS  OF  GENERATION 


posterior   vaginal    \vall,  and    .strong  tendinous    and    muscular   tissue. 
Both  segments  spring  strong!}-  from  powerful  bony  supports.     So  one 


Fig.  154. — Retroversion  (redrawn  and  adapted  from  H.  Becker).     Normal  position 
of  uterus,  dotted  lines  showing  1,  2,  3,  degrees  of  retroversion. 

sees  that  malpositions  of  the  uterus  may  be  due  to  numbers  of  intricate, 
complicating,  and  interdependent  causes.     Remember,  too,  that  dis- 


Fig.  155. — Anteversion  (Kelly  and  Noble). 

placements  of  the  uterus  do  not  in  themselves  constitute  disease.   Usually 
those  displacements  are  but  the  index  of  other  underlying  troubles. 


DISPLACEMENTS 


277 


Surgeons  are  called  upon  to  correct  three  common  forms  of  displace- 
ment: (a)  Backward  displacements;  (b)  forward  displacements,  and  (c) 
prolapse  downwa>-d  (procidentia),  and  all  these  displacements  are  wont 
to  be  associated,  primarily  or  secondarily,  with  such  complications  as 
metritis,  ovaritis,  salpingitis,  atresia,  stenosis,  cystitis,  proctitis,  tumors, 
etc.  So  the  resulting  symptoms  may  be  correspondingly  complicated 
and  numerous.  Each  displacement  may  have  its  own  special  symptoms, 
which  in  turn  depend  on  a  various  etiology.  I  have  mentioned  general 
abdominal  ptosis,  with  which  there  is  always  associated  general  ill 
health  and  any  of  the  familiar  constitutional  affections,  such  as  anemia, 


TT^tt/,    0,/A, 


Fig.  156.— Alexander  operation.     Drawing  out  round  ligament  and  stripping  back 
investing  peritoneum  from  the  broad   ligament    (Dudley). 

renal  and  cardiac  disease,  rheumatism,  venereal  disease,  diabetes,  etc. 
Uterine  displacements  may  result  from  these  general  conditions,  or 
they  may  be  coincident  merely,  and  by  their  presence  add  to  the  woman's 
misery. 

Symptoms  may  be  referred  to  the  pelvic  organs  or  to  the  nervous 
system.  They  may  be  absent  at  times;  they  are  often  influenced  by 
posture,  exercise,  and  diet.  One  observes  dysmenorrhea,  menorrhagia, 
sterility,  recurring  abortions,  constipation,  frequent,  painful,  or  copious 
micturition.  There  may  be  sundry  neuralgias,  hysteria,  dyspepsia, 
headaches,  and  blurring  of  vision.     The  diagnosis  must  rest  upon  the 


278 


FEMALE  ORGANS  OF  GENERATION 


L 


Fig.  157. — Alexander's  operation — second  step. 


Fig.  158. — Alexander's  operation — third  step. 

findings  of  examination :  bimanual  palpation,  inspection  with  the  spec- 
ulum, and  the  passage  of  the  uterine  probe.     Thus  the  position  of  the 


DISPLACEMENTS 


279 


uterus,  as  well  as  the  presence  of  complicating  disease,  can  be  ascer- 
tained. 

Retroversion  of  the  womb  is  illustrated  by  the  figures,  and  usually 
we  recognize  four  stages  or  degrees. 

Treatment  of  retroversion  is  by  replacement,  by  the  use  of  pessaries, 
or  by  surgical  operation.  Operation  alone  concerns  us  here.  There  are 
many  operative  procedures.  As  a  preliminary  to  them  all,  treat  associ- 
ated conditions.  Repair  a  torn  cervix  or  a  lacerated  perineum.  Remove 
complicating  myomata,  cysts,  and  diseased  tubes.  Having  thus  rend- 
ered the  surrounding  parts  and  conditions  relatively  normal,  proceed 
to  fasten  up  the  uterus  itself  in  its  proper  position  of  anteversion,  after 
freeing  any  adhesions  which  may  bind  it  down,  and  after  stretching  or 
cutting  abnormally  tight  uterosacral  ligaments. 


Fig.  159.- — Alexander's  operation. 

The  best  measures  for  fastening  forward  the  uterus  aim  at  shortening 
the  relaxed  round  ligaments,  or  at  forming  new  artificial  suspensory 
ligaments  between  the  fundus  uteri  and  the  anterior  abdominal  wall. 
I  use  both  procedures,  and  shall  describe  various  methods  with  some 
few  words  of  advice  to  govern  the  choice.^ 

Shortening  the  Round  Ligaments  Through  the  Inguinal  Canal  {Alex- 
ander's Operation) . — This  method  carries  with  it  the  dignity  of  custom, 
authority,  and  considerable  age,  but  it  is  often  unsatisfactory,  and  should 
be  undertaken  in  selected  cases  only.  The  plan  of  the  operation  is  to 
shorten  the  round  Hgaments  through  the  inguinal  canal,  and  thus  to  hold 
up  and  forward  the  displaced  uterus. 

1  See  important  paper  by  W.  P.  Graves  on  Retroversion  and  Its  Treatment,  an 
analysis  of  500  cases,  Boston  Med.  and  Surg.  Jour.,  July  4,  1907. 


280 


FEMALE  ORGANS  OF  GENERATION 


The  patient  should  be  carefully  prepared  by  shaving  and  scrubbing, 
as  for  abdominal  section.  'J'he  injiuinal  canal  is  then  exposed  by  incising 
over  it,  in  a  line  parallel  to  Poupart's  ligament,  about  two  inches  above 
the  ligament  and  starting  from  the  pubic  spine  on  either  side.  Having 
discovered  the  canal,  you  may  slit  it  up,  or  nick  it  in  its  upper  portion 
over  the  internal  ring  and  hook  out  the  contents.  Among  these  con- 
tents lies  the  round  ligament,  often  considerably  attemuited  and  some- 
times hard  to  find.     The  uterus  should  then  be  elevated  with  the  fingers 


Fig.   160. — Suspension  of  uterus — step   1. 

in  the  vagina,  or  with  a  preliminary  packing,  and  in  any  case  such  a 
packing  should  be  left  in  the  vagina  for  three  days  after  the  operation  in 
order  to  relieve  pain  and  the  strain  on  the  ligaments.  Having  found 
the  ligaments  in  the  canal,  one  may  secure  them  in  various  ways,  after 
drawing  them  fonvard  and  stripping  back  the  process  of  peritoneum — 
the  canal  of  Nuck.  They  may  be  doubled  upon  themselves  and  sewed 
into  the  canal,  or  the  ends  may  be  pushed  subcutaneously  across  the 
median  line  and  sewed  to  each  other  where  they  overlap.     The  abdom- 


DISPLACEMENTS 


281 


inal  wound  should  then  be  closed,  and  the  patient  should  be  treated  as 
after  any  laparotomy,  but  eighteen  days  on  the  back  should  be  insisted 
upon. 

This  operation  is  suitable  for  a  young  woman  with  normal  uteiiis, 
free  from  adhesions  and  complications.  In  no  other  case  is  it  to  be 
recommended. 

Suspension  of  the  uterus  through  the  vagina  is  to  be  mentioned  only 
to  be  condemned.  It  is  entirely  unsuitable  when  complications  exist, 
and  in  any  case  it  fastens  the  utems  in  a  position  of  abnormal  antever- 
sion,  with  the  great  probability  of  causing  pressure  on  the  bladder  with 
distressing  bladder  symptoms. 


Fig.  161. — Suspension  of  uterus — step  2. 


Suspension  of  the  uterus  through  abdominal  section  is  the  method  to 
be  employed  in  most  cases,  for  through  the  open  abdomen  alone  can 
comphcations  and  adhesions  be  discovered  and  treated.  No  surgeon 
can  determine  always  the  presence  and  extent  of  complications  b}'  bi- 
manual touch  with  the  abdomen  unopened. 

The  methods  of  operating  by  the  abdominal  route  are  numerous,  and  I 
shall  describe  two  of  them.  The  patient  should  be  placed  in  the  Tren- 
delenburg position,  at  an  angle  of  about  45  degrees. 

Peritoneal  Suspension. — Find  the  uterus  and  free  it  from  all  adhesions ; 
treat  appropriately  diseased  tubes  and  ovaries,  and  remove  mj'omata; 
draw  the  uterus  forward  into  the  position  of  normal  anteversion,  and 
with  stout  silk  or  catgut  stitches  passed  through  the  posterior  aspect  of 


282  FEMALE  ORGANS  OF  GENERATION 

the  fundus,  fasten  it  to  the  peritoneum.  Then  sew  up  the  peritoneum  and 
repair  the  abdominal  wall  by  layers.  The  stitches  must  be  passed  deeply 
through  the  uterine  muscle,  using  the  anterior  uterine  wall  in  3'oung 
women,  the  posterior  wall  if  the  patient  is  past  the  menopause.^  The 
result  of  this  operation  is  that  the  uterus  in  a  few  weeks  becomes  sus- 
pended from  the  peritoneum  by  one  or  more  processes  of  tissue  which 
form  new  suspensory  ligaments.  The  objections  sometimes  urged 
against  this  operation — that  the  new  ligaments  may  become  the  cause  of 
intestinal  strangulation  and  that  subsequent  pregnancies  are  interfered 


Fig.  162. — Suspension  of  uterus — step  3. 

with — does  not  seem  to  hold  good  when  the  operation  is  properly 
performed. 

Shortening  the  round  ligaments  by  the  intra-abdominal  route  is  an 
excellent  operation,  and  one  which  I  have  performed  many  times  sat- 
isfactorily, combining  the  methods  of  Gilliam,  Noble,  Mayo,  and  Fowler. 
For  this  operation  enter  the  abdomen  by  a  transverse  incision  above  the 
pubes,  opening  through  the  skin  and  aponeurosis  (Pf annensteil) ,  taking 
pains  with  gauze  dissection  to  strip  clean  for  five  inches  about  the 
wound  the  aponeurosis  and  the  underlying  recti  muscles.  Then,  with 
good  retraction,  split  between  the  recti  and  open  the  peritoneum.  I 
favor  this  transverse  incision  for  entering  the  abdominal  cavitj^,  in  this 
and  other  pelvic  operations  of  lesser  magnitude,  because  it  gives  a 

^W.  H.  Baker's  modification  of  this  operation  (commonly  attributed  to  H.  A. 
Kelly)  is  popular.  Baker  pass'es  two  suspension  stitches,  each  at  the  comua  of  the 
uterus. 


DISPLACEMENTS 


283 


resulting  scar  of  great  strength,  while  the  exposure  is  ample.  Hav- 
ing opened  the  peritoneum  and  relieved  the  uterus,  seek  the  round  liga- 
ments in  the  broad  ligament  and  put  them  on  the  stretch  by  hooking 
them  away  from  the  inguinal  ring.  Then  make  a  new  canal  for  them  by 
drawing  them  through  the  border  of  the  recti  muscles,  and  fasten  them 
together  in  front  of  the  recti,  sewing  them  outside  of  the  aponeurosis, 
This  operation  is  superior  to  that  of  Alexander  for  two  reasons :  it  enables 
the  operator  to  explore  and  treat  the  pelvis,  and  to  deal  with  the  strong 


:fui-k  o.  )^u 


Fig.  163. — A  method  of  suspending  the  uterus — step  3. 


proximal  portions  of  the  ligaments,  rather  than  with  the  frayed-out  and 
weakened  distal  portions.  Moreover,  it  enables  him  to  secure  the  uterus 
in  a  normal  position  and  to  leave  it  freely  swinging,  and,  under  advan- 
tageous conditions,  for  a  possible  subsequent  pregnancy.  Several  of 
my  patients  so  treated  have  borne  children  aften\-ard,  while  the  preg- 
nancies and  labors  have  been  in  no  way  affected  b}'  the  operation. 

Other  methods  of  shortening  the  round  ligaments  within  the  abdomen 
are  advocated  and  practised,  but  I  do  not  recommend  them  because  they 
depend  upon  some  form  of  infolding  or  doubling  of  the  strong  portion  of 


284 


FEMALE  ORGANS  OF  GEXERATIOX 


the  ligaments,  but  leave  the  ah-eady  weak  distal  attachments  in  the 
inguinal  canal  without  reinforcement. 

Retroflexion  of  the  uterus  is  commonly  associated  with  retro- 
version, and  is  due  to  much  the  same  causes.  Karely,  it  is  congenital. 
Infections,  the  pressure  of  tumors,  and  too  early  getting  up  after 
childbirth  are  the  main  factors  in  the  etiology  of  acquired  retroflexion. 
The  sympto»)s  are  such  as  I  have  already  described  when  s])eaking  of 
retroversion,  but  particularly  one  observes  painful  and  difficult  defeca- 
tion, frequent  dyspareunia,  and  constant  dragging  or  bearing-down  pain 
in  the  region  of  the  coccyx.  The  onl}^  satisfactory  treatment  is  by  opera- 
tion through  the  abdomen.  Kcmove  the  causes,  straighten  the  organ 
after  it  has  been  dilated  and  cureted,  and  fasten  it  forward. 


164. — Shortening  the  round  liframents. 


Anteversion  of  the  uterus  is  a  more  nearly  normal  condition  than  is 
retroversion,  but  pathologic  anteversion  is  much  rarer  than  is  retrover- 
sion. When  anteversion  does  occur,  it  is  sometimes  associated  with  path- 
ologic anteflexion.  The  causes  of  anteversion  are  adhesions,  tumors,  and 
metritis.  Rarely,  it  may  be  congenital.  The  symptoms  of  anteversion 
are  trifling,  except  when  it  is  associated  with  anteflexion.  (See  Ante- 
flexion.) The  diagnosis  of  anteversion  is  made  readily  by  bimanual 
touch,  when  the  fundus  is  foimd  to  lie  against  the  bladder,  with  the  cer- 
vix pointing  upward  and  backward  toward  the  sacral  promontory. 

The  treatment  of  anteversion  is  so  closely  associated  with  the  treat- 
ment of  its  complications,  or  with  the  treatment  of  an  accompanying 
anteflexion,  that  one  must  expend  one's  efforts  on  finding  a  remedy  for 
these  complications.     The  old-fashionetl  treatment  by  pessaries  rarely 


DISPLACEMENTS 


285 


avails  an3'thing,  for  pessaries  do  not  touch  the  comphcations.  Inflamma- 
tions of  the  mucosa  nmst  be  treated  by  dilatation,  cureting,  and  the  ap- 
plication of  iodin  crystals,  dissolved  in  95  per  cent,  carbolic  acid.  Ante- 
flexion must  be  treated  as  I  shall  describe  in  a  succeeding  paragraph,  while 
para-uterine  inflammations  and  tumors  can  be  reached  through  abdom- 
inal section  only.  Indeed,  you  will  be  driven  to  exploration  of  the  ab- 
domen in  man}^  of  these  cases,  and  not  infrequently  you  will  find  that 
hysterectomy  alone  will  restore  the  patient  to  health.  The  result  of 
h}'sterectomy  in  the  case  of  elderly  women  for  years  the  subjects  of 
pelvic  irritation,  vesical  pain,  and  frequency  of  micturition  I  have  often 
found  to  be  extremely  gratifying. 

Anteflexion  of  the  uterus  is  not  always  distinguishable  to  the  tyro 
from  anteversion.     Anteflexion  means  that  the  uterine  body  is  bent  at 


Fig.  165. — Retroflexion  of  the  uterus  (Kelly  and  Noble). 


an  angle  with  the  cervix.  On  examination  you  will  find  the  fundus  in 
apparently  normal  position,  or  perhaps  tipped  over  against  the  bladder, 
while  the  cervix  points  forward  into  the  vaginal  canal  instead  of  point- 
ing backward  toward  the  coccyx  in  line  with  the  fundus.  There  may  be 
all  manner  of  variations  from  this  position,  and  flexions  may  be  com- 
plicated with  versions.  The  etiology  of  anteflexion  is  not  always  ap- 
parent. The  condition  may  be  congenital  and  may  be  due  to  inflam- 
mations or  to  tumors. 

The  symptoms  are  similar  to  those  of  anteversion,  with  the  addition 
that  bladder  irritation  is  apt  to  be  more  urgent,  and  dysmenorrhea  more 
painful  throughout  the  flow,  while  sterility  is  extremely  common. 
The  diagnosis  is  made  by  the  sense  of  touch,  while  one  must  appreciate 
that  the  fundus  is  bent  at  an  angle  with  the  cervix.  An  erroneous  diag- 
nosis of  anteflexion  is  often  due  to  the  presence  of  a  myoma  in  the  an- 


286 


FEMALE  ORGANS  OF  GENERATION 


terior  wall  of  the  fundus — a  mjoma  which  gives  to  the  examiner  the 
impression  that  this  tumor  is  the  fundus  itself  bent  fonvard.  Explora- 
tion with  the  uterine  probe  is  necessary  to  correct  this  false  impression. 
The  treatment  of  anteflexion  is  palliative  or  radical.  In  the  case  of  an 
unmarried  woman  or  a  married  woman  who  has  not  borne  children, 
whose  sterility  is  evidently  due  to  the  flexion,  the  deformity  ma}-  be 
corrected  by  thorough  dilatation  and  cureting  and  the  wearing  of  a  hol- 


.Z'- 


Fig.  166. — Dudley's  operation  for  anteflexion  of  uterus — step  1.     Patient  in  Sims' 
position,  cer\-ix  held  down  with  double  hook  tenaculum,  scissors  introduced. 

low  glass  stem  for  several  weeks.  A  previously  sterile  woman  may 
promptly  become  pregnant  after  this  operation,  and  the  deformity  may 
thus  be  cured,  but,  as  a  rule,  the  flexion  will  return  after  dilatation  and 
cureting  only. 

E.  C.  Dudley's  operation  is  one  I  have  practised  with  satisfaction. 
It  is  illustrated  by  the  figures.  Dilate  the  uterine  canal  and  curet  it, 
then  perform  the  following  plastic  operation :  draw  down  the  cervix  and 
divide  it  backward    in   the  median  line,  past  the  uterovaginal  attach- 


DISPLACEMENTS 


287 


mcnt,  nearly  to  the  uteroperitoneal  fold;  hold  the  cut  surfaces  widely 
apart  and  deepen  the  wound  in  the  uterine  wall  with  a  knife.  Then 
excise  from  either  side  of  the  cut  surface  a  small  triangular  notch,  as 
shown  in  Fig.  167.     Fold  back  the  flaps  and  approxinuitc  the  cut  edges 


Fig.  167.- — Dudley's  operation  for  anteflexion  of  the  uterus — step  2.  The  cut 
surfaces  held  apart  by  tenacula.  The  dotted  hnes  show  wedge-shaped  pieces  to  be 
removed  by  scissors,  in  order  to  make  the  cut  surfaces  more  readily  fold  upon  them- 
selves.    Suture  designed  to  fold  cut  surfaces  on  themselves,  in  place,  but  not  tied. 

from  before  backward,  enlarging  and  changing  the  direction  of  the 
canal  on  the  same  principle  as  that  employed  in  a  Heineke-Mikulicz 
pyloroplasty.     It  is  well  to  use  silkworm-gut  for  this  suture.     As  a 


Fig.  16S. — Dudley's  operation  for  anteflexion  of  the  uterus — step  3.  Suture 
shown  in  Fig.  167  tied,  and  additional  sutures  designed  to  fortify  this  one  also  in- 
troduced and  tied.     This  ordinarily  completes  the  operation. 

result  of  this  maneuver  the  cervix  is  straightened  backward  and  is  made 
to  point  in  the  axis  of  the  fundus.  Dudley  points  out  that  in  some  cases 
there  remains  an  abnormally  long  anterior  lip. 


288  FEMALE  ORGANS  OF  GENERATION 

Descent  of  the  Uterus  and  Procidentia. — The  various  malposi- 
tions of  the  uterus  which  1  have  descriljed  are  frequently  associated 
with  a  general  descent  of  that  organ,  and  prolapse  of  the  uterus  through 
the  vagina,  even  to  the  extent  of  its  protrusion  through  the  vulva,  is 
common.  After  protrusion  through  the  vulva  the  condition  is  called 
procidentia.  Procidentia  must  not  be  confounded  with  inveision. 
Persons  with  prolapse  of  the  uterus  are  commonly  women  who  have  borne 
children  and  have  suffered  from  extensive  weakening  of  the  uterine  liga- 
ments and  wide  lacerations  of  the  pelvic  floor.  But  descent  of  the  uterus 
is  not  confined  to  such  persons.  Occasionally,  one  finds  uterine  pro- 
lapse in  women  who  have  never  been  pregnant,  but  whose  uterine 
supports  have  been  weakened  by  hard  work,  constant  standing,  or  pres- 
sure from  above.   These  factors  are  often  found  also  in  the  case  of  women 


Ajter     n.Drodel. 

Fig.  169. — Complete  prolapse  of  the  vagina  and  utenjs,  with  retroflexion  (procidentia). 

who  have  borne  children.  The  figure  illustrates  the  nature  of  descensus 
uteri.  At  first  the  organ  sinks  low  in  the  pelvis,  assumes  a  position  of 
retroversion  parallel  with  the  vaginal  axis,  and  then  falls  lower  and 
lower,  infolding  the  vagina  below  it  until  the  whole  uterus  drops  out 
through  the  vulva.  There  is  associated  with  this  prolapse  a  stretching 
of  the  bladder  and  rectum,  so  that  one  finds  accompanying  cystocele  and 
rectocele.  Such  uteri  are  usually  found  to  be  heavy,  engorged,  subin- 
voluted,  inflamed,  lacerated,  and  often  the  seat  of  tumors  and  retention 
cysts.  The  symptoms  are  constant  and  distressing,  as  I  have  already 
stated  when  describing  the  general  symptoms  of  uterine  displacements. 
Furthermore,  the  presence  of  the  uterus  outside  the  vulva  is  a  continual 
irritation,  while  the  rectal  and  vesical  distress  becomes  almost  unen- 
durable.    The  diagnosis  is  generally  obvious,  but  if  one  is  in  doubt  as 


DISPLACEMENTS 


289 


to  the  extent  of  the  descensus,  when  the  patient  is  lying  on  her  back,  he 
nuiA'  reacUly  solve  the  question  by  having  her  stand  up  and  strain,  when 
the  uterus  will  protrude  to  its  limit. 

Treatment  of  Procidentia. — We  need  not  concern  ourselves  here  with 
palliative  measures,  such  as  replacement  and  the  use  of  pessaries. 
Pessaries  may  be  our  only  resource  in  the  case  of  old  and  feeble  persons, 
but  the  only  hope  of  radical  cure  lies  in  some  form  of  operation.  Let  me 
warn  the  student  that  operations  for  prolapse  of  the  uterus  are  often 
disappointing  in  the  long  rim,  even  after  the  organ  seems  to  have  been 
effectual}}'  secured  high  within  the  pelvis.     The  first  desideratum  is  a 


Fig.  170. — Primarj'  prolapse  of  the  uterus. 

sound  perineal  floor,  and  the  repair  especially  of  the  strong  supporting 
levator  ani  muscle.  I  shall  describe  this  repair  in  Chapter  XII.  But 
even  with  the  perineal  floor  repaired,  a  heavy  uterus,  armed  with  a  long 
conic  cervix  and  othei'AS'ise  unsupported,  may  still  worm  its  way  clown 
through  the  tightest  perineum.  The  terms  pelvic  hernia  and  perineal 
hernia  have  been  applied  to  this  condition  of  prolapse.  The  condition 
is  properly  one  of  hernia,  so  that  after  hysterectomy  even  one  may  find  a 
protnision  of  the  abdominal  viscera  through  the  weakened  pelvic  outlet. 
In  severe  cases  of  procidentia,  therefore,  the  surgeon  is  forced  to  some 
form  of  abdominal  operation  in  addition  to  his  repair  of  the  perineum, 
and  it  may  be  well  also  to  amputate  a  long  cervix.     If  one  be  forced 

]9 


290 


FEMALE  ORGANS  OF  GENERATION 


to  open  the  abdomen,  he  should  carefully  ascertain  the  state  of  all  the 
abdominal  viscera.  He  should  remove  tumors  and  should  treat  ap- 
propriately the  products  of  inflammation.  Ovarian  cysts  and  uterine 
myomata  are  frecjucnt  complications  of  procidentia,  and  their  removal 
alone  may  suffice  for  its  cure.  If  the  uterus  is  small  and  in  fairly  healthy 
condition,  anchor  it  to  the  anterior  abdominal  wall.  This  operation  of 
anchoring  is  pro])erly  called  ventrofixation,  and  is  a  quite  different  matter 
from  that  ventroauspension  which  1  have  (lescril)ed.  To  fix  the  uterus, 
denude  a  considerable  patch  of  peritoneum  from  its  fundus, — a  patch  as 


-^ 


Fig.  171. — Operation  for  prdcidentia)  as  suggested  byG.  W.  Crile.     Dotted  line  in- 
dicates line  of  incision — .step  1. 


large,  at  least,  as  a  fifty-cent  piece, — and  attach  the  uterus  firmly  at 
the  denuded  portion  to  the  anterior  abdominal  wall,  passing  the  stitches 
deeply  through  parietal  aponeurosis,  recti  muscles,  peritoneum,  and 
uterus.  This  maneuver  results  in  establishing  broad  and  firm  adhe- 
sions, which  should  not  stretch  or  allow  subsequent  sagging  of  the 
uterus. 

If  this  operation  prove  unsuccessful,  it  may  be  necessary  to  perform 
hysterectomy,  which  may  be  done  either  by  amputating  the  uterus 
through  the  cervix,  or  by  removing  the  whole  organ  and  closing  the 
vagina.     If  the  uterus  is  amputated  through  the  cervix,  the  shortened 


DISPLACEMENTS 


291 


stumps  of  the  round  ligaments  should  be  stitched  to  the  cervical  stump 
for  extra  support  of  the  perineal  floor.  But,  as  I  have  said,  total  hys- 
terectomy does  not  insure  the  patient  against  a  perineal  hernia.  To 
insure  against  hernia,  various  operations  have  been  devised,  but  I 
recommend  that  advocated  by  G.  W.  Crile,  as  I  have  employed  it  fre- 
(juently  and  with  great  satisfaction  during  the  past  fi^■e  years.  Briefly, 
his  operation  is  this :  Having  opened  the  abdomen,  seize  the  uterus  and 
draw  it  up;  tie  off  the  ovarian  arteries;  perform  a  modified  supravaginal 
hysterectomy,  leaving  long  lateral  tabs  or  fish-tails  projecting  up  from 
either  side  of  the  cervix,  and  suspend  the  cervix  by  these  long  fish-tails, 


Fig.  172. — Operation  for  procidentia,  after  Crile — step  2. 


drawing  them  through  the  bodies  of  the  recti  muscles,  and  stitching 
them  together  much  as  the  round  ligaments  are  stitched  together  above 
the  recti  in  suspending  the  retroverted  uteiTis. 

After  any  of  these  operations  upon  the  prolapsed  uterus  a  long  period 
of  rest  and  care  is  needed.  These  women  are  usually  debilitated  from 
prolonged  suffering  and  their  tissues  are  relaxed  and  toneless.  They 
have  been  the  subjects  of  aggravated  forms  of  hernia,  which,  at  the  best, 
have  not  been  adequately  repaired  or  restored  to  natural  conditions, 
so  that  convalescence  is  tedious,  demanding  special  care  and  upbuilding. 


292  FEMALE  ORGANS  OF  GENERATION 

(\  TUMORS  OF  THE  UTERUS 

Forty  years  ago  amputation  at  the  hip-joint  was  the  great  capital 
operation  of  surgery — rare  and  interesting.  It  was  said  that  no  sur- 
geon had  won  his  spurs  until  he  had  i)erfornied  this  oi)cration  success- 
fully. Twenty-five  years  ago  ovariotomy  took  the  leading  phice  in  the 
estimation  of  operators,  and  fifteen  years  ago  hysterectomy  was  to  the 
fore.  To-day,  surgeons  who  are  busied  with  new  questions  are  ventur- 
ing into  other  fields,  but  hysterectomy  and  other  serious  operations  on 
the  uterus  still  hold  an  important  place  in  surgical  literature.  The  his- 
tory of  hysterectomy  is  recent,  and  every  surgeon  of  fifteen  years'  expe- 
rience remembers  the  use  of  the  Koeberle  clamp,  and  how  we  fastened 
the  cervical  stump  outside  of  the  abdominal  cavity.  But  interest  in 
hysterectomy  is  far  more  ancient.  It  was  probably  practised  b}'  the 
Greeks;  it  was  performed  in  1560  by  Andreas  a  Cruce;  von  Langenbeck 
removed  the  uterus  in  1813;  Sauter,  in  1822,  and  sundry  other  operators, 
until  we  come  to  such  well-known  moderns  as  Billroth,  von  Mikulicz,  and 
Freund.  In  1887  Dudley  had  collected  38  cases  by  American  surgeons, 
while  to-day  it  is  one  of  the  commonest  operations  known  in  our  amphi- 
theaters. 

Myoma 

The  most  frequent  tumors  of  the  uterus  are  myomata,  which  are  non- 
malignant  growths  composed  of  non-striated  muscle-fibers  and  fibrous 
connective  tissue.     The  old  term  is  "  fibroid,"  or  "  fibromyoma,"  but, 


Fig.  173. — Myoma  of  uterus,  showino;  greatly  distended  veins. 

in  fact,  all  these  tumors  arise  from  muscle  substance  and  connective 
muscular  elements,  though  the  fibroid  character  often  may  predominate. 
We  do  not  know  the  cause  of  these  tumors.  They  grow  during  the 
period  of  sexual  maturity.  Rarely  they  appear  before  puberty  or  after 
the  menopause.     They  are  more  common  among  negroes  than  whites. 


TUMORS   OF   THE    UTERUS 


293 


There  is  no  satisfactory  evidence  that  they  arise  from  traumatisim. 
Myomata  vary  in  size  from  a  pea  to  a  mass  larger  than  a  child's  head; 
they  may  be  multiple  or  single;  they  may  be  hard  or  soft,  depend- 
ing upon  the  preponderance  of  fibrous  elements  and  the  character  of 
the  blood-vessels,  for  sometimes  the  veins  reach  a  great  size  and  appear 
as  dilated  sinuses. 

According  to  the  site  of  these  tumors  they  are  designated  variously 
as  submucous,  intramural,  and  subserous;  they  may  undergo  certain 
secondary  changes:  fatty  degeneration;  mucoid  degeneration;  cystic 
degeneration;  calcification;  septic  infection,  and  malignant  changes. 
Submucous  fibroids  encroach  upon  the  lumen  of  the  uterus  and  may  ob- 
struct it  or  render  it  tortuous.  They  may  be  pedunculated,  and  hang 
clown  as  polypi  in  the  uterus,  and  they 
may  protrude  from  the  os.  Intramural 
myomata  are  usually  multiple,  and  often 
cause  an  apparent  enlargement  of  the 
whole  uterus,  so  that  the  organ  may  seem 
to  fill  the  abdominal  cavity  and  distend 
its  walls,  giving  the  appearance  of  preg- 
nancy at  full  term.  Subserous  myomata 
may  be  single  or  multiple,  and  may  be 
associated  with  other  forms  of  myomata 
— intramural  and  submucous.  Subserous 
fibroids  may  appear  merely  as  excres- 
cences beneath  the  serosa,  or  ma}^  be 
pedunculated.  Rarely  isolated  myomata 
free  in  the  abdominal  cavity  have  been 
described.  Subserous  fibroids  may  pro- 
ject from  the  sides  of  the  uterus  and  dis- 
tend the  broad  ligaments,  in  which  case 
the}^  are  known  as  intraligamentous  m^'omata.  Commonly  these  uterine 
tumors  are  in  the  fundus,  but  infrequently  they  develop  in  the  cervix, 
and  they  may  appear  in  the  vaginal  portion  only. 

The  s)miptoms  of  uterine  myomata  may  be  numerous  and  distress- 
ing, or  there  may  be  no  symptoms.  The  disease  may  first  make  itself 
known  during  a  pregnancy,  at  which  time  the  tumor  may  grow  rapidly. 
The  common  and  alarming  sjanptom  of  mj^omata  \siJiemorrhage.  This 
hemorrhage  is  due  to  endometritis,  dependent  on  irritation  by  the 
growth.  The  blood  does  not  come  directly  from  the  tumor  itself.  The 
flow  comes  on  gradually,  not  suddenly  and  profusely,  as  is  the  case  with 
hemorrhage  from  cancer.  The  patient  notices  that  her  menstrual 
periods  come  more  frequently  than  common,  and  that  the  flowing  is 
more  abundant  and  more  prolonged.  This  condition  persists,  and  the 
disturbance  increases  until  eventualh"  the  patient  may  be  the  victim  of 
frequent  attacks  of  long-continued  and  alarming  hemorrhage,  prostrating 
her  and  threatening  life  even.  The  advent  of  the  menopause  may  or 
may  not  affect  the  hemorrhages.  Sometimes  the  tumor  shrinks  at  that 
period  and  the  hemorrhage  ceases.     In  other  cases  the  menopause  seems 


Fig.  174. — Polypi  in  uterus. 


294 


FEMALE  ORGANS  OF  GENEHATION 


to  be  the  signal  for  ronowcd  activity  on  tlic  jnirt  of  the  tumor,  which 
grows  and  causes  more  hemorrhage  tiian  ever. 


Fig.  175. — Large  submucous  myoma  (H.  A.  Kelly).  Adapted  to  removal  by 
abdominal  section  by  splitting  open  the  uterus  and  enucleating  the  tumor,  and  then 
sewing  up  the  uterine  incision. 


Fig.  176.— Myomata. 

The  symptoms  of  pressure,  traction,  pain,  and  discomfort  are  next  in 
importance  to  hemorrhage.  The  causes  and  nature  of  these  symptoms 
are  obvious  when  one  considers  the  position  of  the  uterus  and  its  rela- 


TUMORS    OF    THE    UTERUS  295 

tions  to  other  orp;ans.  In  most  cases  the  uterus  itself  becomes  somewhat 
enlarged,  although  an  actual  increase  in  the  uterine  body  is  not  invari- 
able. With  its  associated  tumors  it  may  press  downward  or  upward, 
backward  or  forward.  It  may  drag  or  press  upon  the  rectum,  the  blad- 
der, the  urethra,  the  vagina,  and  may  interfere  with  the  functions  of  the 
intestines  and  other  abdominal  organs,  for  it  may  become  inflamed 
and  set  up  adhesions.  As  a  result  of  all  these  derangements  there  may 
be  obstinate  constipation,  frequent  micturition,  leukorrhea, — dysmen- 
orrhea is  common, — pain  in  the  region  of  the  coccyx  or  sacrum,  colicky 
stomachache,  dyspepsia,  headache,  nausea,  blurring  of  vision,  and  many 
other  indefinite  abdominal  and  general  nervous  symptoms. 


Fig.  177. — Adhesions  to  uterine  myoma. 

The  diagnosis  of  uterine  myoma  is  not  so  easy  as  would  appear. 
Especially,  these  tumors  must  be  distinguished  from  tumors  of  the  ovary 
and  from  intraligamentous  cysts.  Often  it  is  extremely  difficult  to 
distinguish  a  tense  cyst  from  a  soft  myoma.  The  common  symptom 
of  hemorrhage  is  not  pathognomonic  of  myoma ;  associated  growths  and 
extensive  adhesions  may  render  obscure  the  diagnosis  to  the  examining 
hands.  The  surgeon  should  make  a  bimanual  examination  and  map  out 
the  lower  portion  of  the  mass  with  fingers  in  the  rectum  as  well  as  in  the 
vagina.  He  should  also  endeavor  to  distinguish  a  uniform  myomatous 
enlargement  of  the  uterus  from  a  pregnancy— often  an  extremely  diffi- 


29G  FEMALE   OllOAXS    OF    OEXEKATION 

cult  matter.  In  this  connoction  he  should  ascertain  accurately  the 
time,  character,  and  amount  of  hemorrhage,  the  condition  of  the 
breasts,  and  the  presence  or  absence  of  a  fetal  heart.  Pregnancy  may 
be  present  in  a  myomatous  uterus.  The  uterine  probe  is  a  valuable  ad- 
junct in  making  the  diagnosis  of  myoma,  antl  usually  it  can  be  employed 
when  the  question  of  a  possible  pregnancy  has  been  eliminated.  The 
probe  will  follow  the  uterine  canal  often  to  a  considerable  depth, — 1,  6, 
or  8  inches, — and  by  its  means  one  may  demonstrate  the  relation  of  the 
uterus  itself  to  the  associated  new-growth.  Other  conditions  to  be 
differentiated  from  myoma  are  malignant  growths,  chi'onic  metritis, 
inversions  and  displacements  of  the  uterus,  incomplete  abortion,  disease 
and  pregnancy  in  the  tubes,  and  floating  kidney. 

The  prognosis  of  uterine  myoma  is  a  much-debated  question. 
Deaver  ^  wrote  an  extremely  interesting  article  on  the  subject  a  few  years 
ago,  and  claimed  that  the  great  majority  of  these  cases  come  to  no  harm 
if  let  alone.  It  is  a  fair  estimate  that  of  all  women  over  thirty-five 
years  of  age  20  per  cent,  are  subjects  of  these  growths,  and  undoubtedly 
great  numbers  of  such  women  have  no  special  discomfort  beyond  some 
increase  of  the  normal  flowing  and  some  enlargement  of  the  abdomen. 
As  opposed  to  Deaver's  view,  many  gynecologists  assert  that  every 
uterine  myoma  should  be  removed  on  account  of  the  danger  to  life  from 
hemorrhage,  exhaustion,  and  possible  malignant  degeneration.  That 
question  of  malig-nant  degeneration  is  extremely  important;  some  statis- 
tics show  that  not  more  than  5  per  cent,  of  these  growths  become  malig- 
nant. However  that  may  be,  every  surgeon  of  experience  has  seen  cases 
of  myoma  associated  with  mahg-nant  changes,  and  in  view  of  this  fact 
one  caimot  but  regard  such  malignant  degeneration  as  possible  in 
every  case  of  myoma.  On  the  whole,  one  agrees  with  Deaver  that 
the  majority  of  myomata  do  not  endanger  life,  but  one  should  bear  in 
mind  the  possible  dangers  and  should  take  his  measures  accordingly. 
My  own  practice  is  to  advise  removal  of  the  tumor,  the  patient's  general 
condition  permitting,  in  all  cases  in  which  symptoms  are  persistent  dur- 
ing the  age  of  menstrual  activity ;  and  after  the  menopause,  if  the  tunK)r 
continues  to  grow,  whether  or  not  troublesome  symptoms  be  present. 

The  treatment  of  myoma  uteri  is  oi3erative,  so  far  as  anything  more 
than  mere  palliation  is  concerned,  though  there  are  sundry  traditional 
and  tentative  measures  which  the  practitioner  maybe  tempted  to  follow. 
Tonic  doses  of  ergot  or  ergot  and  hydrastis  canadensis  are  sometimes 
of  value  to  control  hemorrhage — 15  drops  every  four  hours  or  oftener. 
This  dosage,  combined  with  an  ice-bag  over  the  tumor,  may  check  hem- 
orrhage and  allow  of  the  building  up  of  the  patient  preliminary  to 
operation.  Manipulation  of  the  tumor  may  sometimes  relieve  incarcera- 
tion below  the  sacral  promontory,  and  so  enable  the  patient  to  get  along 
with  less  discomfort  and  pain.  Excessive  hemorrhage  may  be  controlled 
by  packing  the  uterus  with  gauze  or  by  steaming.  Steaming  is  remark- 
ably useful  in  some  cases.  The  technic  is  to  introduce  steam  drawn 
from  a  small  "  steamer"  and  carried  through  a  3-  or  4-foot  tube,  armed 
1  Amer.  Med.,  April  15,  1905. 


TIMOUS    OF   THE    UTERUS 


297 


with  a  glass  nozzle,  through  an  intra-titcrine  speculum,  directly  into 
the  cavity  of  the  uterus.  Let  a  stream  of  cold  water  play  over  the  spec- 
ulum to  prevent  its  becoming  superheated;  inject  the  steam  for  forty 
seconds,  then  withdraw  the  nozzle  for  a  couple  of  minutes,  and  introduce 
it  again  for  thirty  seconds.  This  treatment  brings  about  a  necrosis  of 
the  entlometrium  and  results  in  thickening  and  scar  formation — enough, 
often,  to  prohibit  subsequent  hemorrhage.  Do  not  waste  time  with 
styptics  to  control  hemorrhage,  nor  weary  yourself  and  the  patient  with 
elect roh'sis,  which  is  often  dangerous  as  well  as  useless. 

Surgical  operations  for  these  myomata  may  be  performed  through 
the  vagina  or  by  abdominal  section.  The  latter  is  preferable  in  most 
cases.     ]\Ioreover,  these  operations  may  be  conservative  or  destructive 


Fig.   178. — Steamino;  the  uterus. 


— that  is  to  say,  they  may  be  designed  to  remove  the  tumors  or  to  re- 
move the  uterus  with  the  tumors;  and  in  the  latter  case  the  removal  of 
the  uterus  may  be  total  (panhysterectomy)  or  partial  (supravaginal 
hysterectomy). 

In  addition  to  these  operations,  authors  have  claimed  great  things 
for  milder  measures.  Gojttschalk,  of  Berlin,  ties  the  uterine  arteries 
and  claims  thus  to  check  the  progress  oFthe  growths.  ^Martin  ties  the 
broad  ligaments,  but  does  not  include  the  uterine  arteries.  Battey, 
Tait,  and  others  have  claimed  good  things  through  the  removal  of  the 
tubes  and  ovaries;  but  such  procedures  have  not  borne  out  their  first 
promise. 

Vaginal  operations  have  their  place  in  the  treatment  of  myomata, 
and  usually  are  applicable  to  small  tumors.     By  the  vaginal  route  one 


298 


FEMALE  ORGANS  OF  GENERATION 


may  remove  sul)niuc()us  polypi.  By  the  same  route  one  may  remove 
the  whole  uterus  or  may  enucleate  tumors  and  leave  the  uterus.  M}' 
experience  with  vaginal  hysterectomy  for  myoma  does  not  lead  me  to 
recommend  this  method,  although  the  operation  itself  may  be  extremely 
eas}'.  I  cannot  regard  it  as  a  proper  routine  surgical  procedui'e,  because 
it  does  not  allow  of  a  thorough  inspection  of  the  field  and  treatment  of 
complications.  The  presence  of  extensive  adhesions  and  inflamed 
tubes  and  ovaries  may  render  the  vaginal  operation  extremely  difficult, 
and  the  ureters  cannot  always  easily  be  avoidetl.  On  the  whole,  vaginal 
hysterectomy  for  myoma  is  as  difficult  or  more  difficult  than  abdominal 


Fig.  179. — Removal  of  subserous  myoma  of  uterus. 

hysterectomy,  and  the  mortality  is  no  lower.    I  shall  describe  the  technic 
shortly  under  the  topic  Cancer  of  the  Uterus. 

Vaginal  enucleations  and  morcellation  are  operations  of  doubtful 
value.  They  are  blind,  and  unsurgical,  and  they  leave  the  operator  in 
the  dark  as  to  possible  complicating  conditions.  Tumors  confined  to 
the  cervix,  however,  and  pedunculated  growths  in  the  uterine  cavity 
should  be  removed  by  the  vaginal  route.  For  the  removal  of  the  latter 
the  wire  snare  and  scissors  are  generally  sufficient,  but  it  may  be  neces- 
sary to  split  up  the  cervical  canal  in  order  to  allow  of  proper  handling  of 
instruments  within  the  cavity  and  the  removal  of  masses  choking  the  os. 


TUMORS   OF   THK    UTERUS 


299 


Abdominal  Operations. — Myomectomy. — Strangely  enough,  the  con- 
servative operation  of  myomectomy  came  into  general  use  long  after 
the  radical  hysterectomy  had  become  familiar.     By  myomectomy  we 


Fig.  180. — Removal  of  myomata. 

mean  shelling  out  the  myomata,  one  by  one,  from  the  uterus.  The 
operation  is  so  easy  in  appropriate  cases  that  nothing  more  than  the 
illustrations  are  needed  to  demonstrate  it.     Open  the  abdomen;  throw 


Fig.  181. — Uterine  polyp  removed  -u-ith  scissors. 

the  patient  in  the  Trendelenburg  position;  wall  off  the  uterus;  pull  it 
to  the  fore  with  vulsellum  forceps,  and  enucleate  the  tumors  individually 
with  knife,  scissors,  and  fingers.     In  properly  selected  cases  the  opera- 


300 


FEMALE  OKGAXS  OF  GENERATION 


tion  is  cxtrcMnely  easy,  aiul  the  hemorrhagic  into  the  resultin<;-  cavities 
is  readily  couti-ollcd  by  buried  catgut  stitches.  Finally,  sew  iij)  the 
wound  in  the  uterus  and  suspend  the  organ  if  it  seems  inclined  to  drop 
back  into  an  abnormal  position,  ^^'ipe  out  the  peritoneal  cavity;  re- 
place the  omentum,  and  close  the  abdominal  wound.  It  often  requires 
some  nice  surgical  judgment  to  decide  between  myomectomy  and 
hysterectomy.  In  general  terms,  myomectomy  is  preferable  in  case 
the  nuiss  of  tumors  be  of  moderate  size,  and  the  growths  located  mostly 
near  the  surface  of  the  organ.  Myomectomy  for  submucous  polypi  may 
well  be  done  by  the  abdominal  route.     The  operation  consists  in  splitting 


Fig.  182. — Ligation  of  uterine  vessels,  clamp  applied  (adapted  from  Dudley). 

open  the  body  of  the  uterus,  cleaning  out  the  submucous  growths,  and 
treating  the  inflamed  mucosa  with  the  curet  and  weak  carbolic  applica- 
tions. Then  sew  up  the  uterus  with  catgut  stitches,  which  shall  not 
include  the  mucosa.  This  operation  is  eas}^  safe,  and  extremely  effec- 
tive— a  great  advance  over  many  old-time  dilatings  and  curetings. 
Low  cervical  ])olypi  may  be  removed  with  scissors  or  the  wire  snare. 

Supravaginal  hiisteredoniy  is  the  operation  of  common  choice  in  cases 
of  myoma  uteri,  and  usually  it  is  not  difficult.  A'olumes  have  been 
written  on  the  technic,  and  most  of  our  best-known  surgeons  and  gyne- 
cologists have  had  their  word  to  say  on  the  matter.  AVhen  all  is  said, 
the  operation  is  simple  enough  when  the  pelvic  conditions  are  uncom- 


TUMORS   OF  THE    ITKIIUS 


301 


plicated.  The  abdomen  is  opened  through  the  left  rectus  muscle  by  a 
liberal  incision,  large  enough  to  permit  of  the  delivery  of  the  tumor, 
when  the  surgeon  seizes  the  mass  with  strong  vulsellum  forceps,  and, 
if  possible,  turns  it  out  through  the  abdominal  wound.  Complications 
may  render  difficult  or  impossible  this  delivery  at  once.  Adherent  viscera 
must  be  carefully  dissected  off  from  the  tumor,  diseased  tubes  and  ovar- 
ies must  be  removed,  incarcerated  masses  must  be  shelled  out  of  the 
pelvis,  and  intraligamentous  growths  must  be  freed  by  splitting  the 
broad  ligaments. 

Having  delivered  the  tumor,  the  next  step  is  the  vitally  important 
one  of  sec\iring  the  four  sources  of  blood-supply,  the  ovarian  and  uterine 


Fig.  1S3. — Fish-tail  incision  for  amputation  above  cervix  (adapted  from  Dudley). 

arteries,  and  this  rarely  is  difficult.  I  prefer  to  double-clamp  the  broad 
ligaments  close  to  the  mass  and  divide  the  tissues  between  the  clamps. 
Then  dissect  off  the  peritoneum  from  the  uterus  about  the  cervix,  just 
above  the  attachment  of  the  bladder.  Push  this  peritoneum  well  do-\^Ti 
on  to  the  cervix,  leaving  exposed  a  broad  strip  of  the  cervical  muscularis. 
Then  pass  a  curved  threaded  needle  about  the  deep-lying  uterine  vessels 
and  tie  tightly.  I  prefer  not  to  use  clamps  for  these  vessels  if  I  can  help 
it,  because  clamps  add  to  the  complication  of  instruments  in  the  narrow 
field.  In  securing  the  uterine  vessels,  and,  indeed,  in  all  manipulations 
about  the  tumor,  one  should  have  in  mind  possible  danger  to  the  ureters. 
These  structures  often  are  greatly  displaced  by  myomata,  and  in  the 
case  of  extensive  intraligamentous  growths  the  ureters  may  appear 


302 


FEMALE  ORGANS  OF  GEXERATION 


to  be  far  out  on  the  side  of  the  tumor.  For  this  reason,  in  the  case  of 
difficult  dissections,  some  operators  do  their  work  after  having  passed 
catheters  through  the  urethra  into  the  ureters. 

The  vessels  being  now  controlled  and  the  ureters  isolated,  amputate 
through  the  cervix  with  knife  or  scissors.  I  prefer  to  make  a  fish-tail 
incision,  which  may  readily  be  closed  like  any  other  amputation  stump, 
and  before  closing  the  stump  I  rim  out  the  cervical  canal  with  the  actual 
cautery,  or  swab  it  with  pure  carbolic  acid.  Then  close  the  cervical 
stump  with  buried  catgut  sutures.  Draw  over  it  and  stitch  in  place  the 
dissected  peritoneum,  and  complete  the  operation  b\'  fastening  the  stump 
of  the  round  ligaments  into  the  remnant  of  the  cervix.  I.  regard  this 
stitching  of  the  round  ligaments  into  the  cervix  as  important  for  the 


Fig.  184. — Suture  of  cervical  stump  (adapted  from  Dudley). 


support  of  the  perineal  floor.  Sagging  of  the  cervical  stump  is  thus  pre- 
vented and  the  bladder  is  kept  properly  supported.  E.  C.  Dudley  ad- 
vocates sewing  the  severed  stumps  of  the  broad  ligaments  to  each  other 
across  the  pelvis.  This  is  an  excellent  maneuver  when  ])Ossible,  but 
the  same  end  is  attained  by  such  a  treatment  of  the  round  ligaments 
as  I  have  described. 

The  question  of  leaving  one  ovary,  or  a  portion  of  an  ovaiy,  in  the 
pelvis  has  agitated  men.  It  is  certain  that  removal  of  both  ovaries  at 
once  from  a  woman  who  has  not  yet  passed  the  menopause  results  in 
more  serious  nervous  disturbances  than  when  ovarian  tissue  is  left. 
After  the  menopause  the  removal  of  both  ovaries  causes  less  disturb- 
ance. 


TUMORS    OF   THE    UTERUS  303 

The  aftor-troatmont  of  these  cases  is  quite  simple  and  consists  in  the 
usual  care  of  diet  and  bowels,  with  rest  in  bed  for  from  two  to  three 


Fig.  185. — Repair  of  round  and  broad  ligaments  (adapted  from  Dudley). 

w^eeks.     If  the  patient  be  tightly  and  properly  swathed,  she  may  be 
turned  about  in  bed  as  soon  as  she  has  recovered  from  ether. 

Total  Hysterectomy  {Panhysterectomy). — In  a  small  number  of  cases 
the  surgeon  may  think  it  wise  to  remove  the  whole  uterus,  including  the 


Fig.   186. — Combined    panhysterectomy,    diseased  tubes    (Massachusetts  General 

Hospital). 

cervix,  for  the  organ  may  be    so  septic  or  otherwise  diseased  as  to 
render  the  presence  of  the  cervix  dangerous  to  the  patient;  or  the  cervix 


304 


FEMALE  OROAXS  OF  CEXEHATIOX 


itself  may  be  involved  in  the  new-<rrowth  to  such  an  extent  as  to  render 
its  removal  imperative. 

The  technic  of  the  operation  is  similar  to  that  of  su])rava<rinal  hys- 
terectomy until  one  comes  to  dealinfr  with  the  vajrinal  portion  of  the 
cervix.     There  are  two  ways  for  such  dealing:  one  may  loosen  the  cervix 


Fig.   187. — Myoma  complicating  pregnancy  (E.  W.  Mulligan's  case). 

from  below  by  a  complete  incircling  incision  through  the  vagina,  and  by 
separating  the  bladder  and  rectum,  taking  pains  not  to  wovmd  the  ure- 
ters; or.  working  from  above,  one  may  perform  the  entire  operation, 
peeling  down  the  para-uterine  tis.sues  until  the  vagina  is  comjjletely 
freed,  after  whifh  that  stmcture  should  be  clamped  and  cut  off,  allowing 


TUMORS   OF  THE    UTERUS  305 

the  removal  of  the  entire  uterus.  The  further  steps  in  the  operation 
in  either  case  consist  in  sewing  up  the  vagina  with  a  continuous  catgut 
ligature,  covering  over  the  vaginal  stump  with  the  replaced  peritoneum, 
and  sewing  together,  so  far  as  possible,  the  severed  edges  of  the  broad 
ligaments  so  as  to  bridge  over  and  reinforce  the  pelvic  fdoor.  It  is  not 
usually  necessary  to  establish  vaginal  drainage,  but  in  case  of  sepsis, 
such  drainage  may  be  essential.  Drain  with  a  gauze  wick  leading  out 
of  Douglas'  fossa,  which  has  been  covered  in  by  the  replaced  peritoneum. 

These  extensive  operations  on  the  uterus  should  be  followed  by  a 
relatively  low  mortality,^ — from  5  to  10  per  cent., — and  in  the  hands  of  a 
practised  surgeon  such  are  the  results. 

Myoma  Complicating  Pregnancy. — This  condition  raises  a  question 
of  extreme  difficulty,  calling  for  the  most  careful  judgment.  Myomata 
are  wont  to  grow  rapidly  during  pregnancy,  and  sometimes  to  interfere 
seriously  with  labor;  but  routine  operation  upon  such  myomata  is  not 
justifiable.  The  following  propositions  are  generally  recognized  as 
sound  by  surgeons  and  obstetricians.  Operations  may  be  postponed 
and  delivery  at  full  term  may  be  expected  in  case  the  tumor  is  small 
and  of  slow  growth,  or  when  it  is  so  placed  in  the  fundus  of  the  uterus 
as  not  to  threaten  obstruction  to  delivery.  Even  when  the  tumor  is  in 
the  pelvis  it  often  rises  above  the  brim  late  in  pregnancy,  leaving  a  free 
passage  for  the  birth  of  the  child. 

On  the  other  hand,  operation  is  to  be  done  if  the  fetus  is  dead,  in 
which  case  abortion  should  be  undertaken,  followed  later  by  a  myomec- 
toni}'  or  hj^sterectomy.  If  the  child  is  alive,  but  cannot  be  born 
through  the  natural  passage,  Cesarean  section  or  hysterectomy  (Porro's 
operation)  must  be  done.  Rarely,  the  surgeon  may  be  able  to  remove 
myomata  W'ithout  interrupting  a  pregnancy. 

If  the  condition  of  pregnancy  complicating  myoma  is  discovered 
before  the  fourth  month,  an  abortion  is  justifiable.  After  that  time  the 
dangers  of  abortion  are  great,  and  one  should  wait  for  full  term  if  possible. 
The  danger  of  abortion  in  late  pregnancy  is  due  to  the  difficulty  of  deliv- 
ering the  placenta  and  the  probability  of  infection  and  hemorrhage. 
The  operations  of  choice  in  late  pregnancy,  therefore,  are  Cesarean  section 
and  hysterectomy.     In  any  case  the  dangers  of  the  condition  are  grave. 

Cancer  of  the  Uterus 

"  A  purulent  or  bloody  vaginal  discharge  occurring  in  a  woman  who 
is  near  the  menopause  or  who  has  passed  the  menopause  should  lead 
the  general  practitioner  to  insist  on  a  local  examination."  ^  I  should 
go  further  than  that,  and  say  that  any  abnormal  flowing  or  persistent 
leukorrhea,  even  in  a  woman  over  twenty-five  years  of  age,  should  lead 
one  to  suspect  the  possibility  of  cancer  of  the  uterus. 

Cancer  of  the  uterus  is  extremely  common;  nearly  one-third  of  all 
cancers  in  women  are  uterine  cancers.  The  thought  of  this  disease  is  in 
the  minds  of  most  women  who  have  fallen  into  ill  health  after  the  meno- 

1  W.  L.  Burrage,  Boston  Med.  and  Surg.  Jour.,  July  24,  1902. 
20 


306 


FEMALE  ORGAXS  OF  GEXERATION 


pause,  for  it  is  a  disease  notoriously  distressing  and  offensive,  and  is  re- 
garded by  the  laity  as  incurable.  Cancer  may  spring  from  any  j)ortion  of 
the  uterine  mucosa — from  the  cylindric  epithelium  of  the  glands  and  from 
the  pavement  e})itheliuni  outside  of  the  external  os;  and  so  the  variety 
of  growth  corresponds  with  the  type  of  epithelium  fiom  which  it  springs. 
Cylindric-cell  carcinoma  may  appear  to  be  situated  outside  of  the 
external  os.  It  is  not  truly  beyond  the  os,  but  springs  from  everted 
cervical  mucosa  lining  an  old  childbirth  laceration.  So  we  have  two 
varieties  of  carcinoma  of  the  uterus: 

(a)   Cylindric-cell  carcinoma,  adenocarcinoma,  gland  carcinoma. 

(6)  Pavement-cell  carcinoma,  squamous  carcinoma,  epithelioma. 

Cancer  of  the  cervix  is  far  more  common  than  is  cancer  of  the  fundus, 
but  cancer  of  the  cervix  may  extend  to  the  fundus.    Both  varieties  of  car- 


n 


je3 


Fig.  188. — Adenocarcinoma  of  the  body  of  the  uterus  cut  through  the  anterior 
wall.  In  spite  of  the  fact  that  the  whole  uterine  cavity  is  clioked  with  the  disease, 
it  does  not  invade  the  cervix  (f  natural  size)  (Kelly). 

cinoma — adenocarcinoma  and  epithelioma — may  be  present  together 
The  tendency  of  adenocarcinoma  is  to  involve  the  submucosa,  and  the 
tendency  of  epithelioma  is  to  confine  itself  to  superficial  areas.  AVhen 
the  deeper  tissues  are  involved,  the  affected  portion  is  enlarged,  hard,  and 
friable.  The  surface  is  smooth,  glistening,  flattened,  or  nodular. 
Either  variety  extends  rapidly  and  ulcerates  readily.  The  margin  of 
the  ulcer  is  hard,  irregular,  and  elevated.  The  base  is  rough  and  bleeds 
easily.  The  process  may  destroy  the  cervix,  and  when  situated  in  the 
cervix,  may  extend  variously  and  involve  the  vaginal  vault,  especially 
in  front  and  at  the  sides;  the  broad  ligaments,  rarely  the  uterine  append- 
ages, the  ureters,  the  bladder,  the  urethra,  and  pelvic  bones;  the  fundus, 
the  iliac  lymph-nodes,  after  having  invaded  the  broad  ligaments; 
this  delay,  says  Dudley,  is  because  the  squamous  cancer-cells  are  too 


TUMORS   OF  THE    UTERUS 


307 


large  to  pass  through  the  lymph  radicles  of  the  cervix,  but  not  too 
hirge  to  traverse  the  lymph-vessels  of  the  ligaments.  Furthermore, 
the  kidneys  may  be  involved  in  nephritis,  hydronephrosis,  or  pyeloneph- 
rosis,  and  dilatation  of  the  ureters  is  common.  Metastatic  cancer  may 
be  found  in  distant  organs. 

Cancer  of  the  body  of  the  uterus  may  extend  in  much  the  same 
fashion,  but  it  implicates  the  lumbar  lymph-nodes  and  abdominal 
organs  more  quickly  than  does  cancer  of  the  cervix. 


^_ 


_sL.l 


Fig.  189. — Inoperable  epithelioma  of  the  cervix  in  which  the  chief  involvement 
is  at  the  internal  os,  where  the  uterus  is  perforated.  In  the  mucous  membrane  of  the 
fundus  a  few  epithelial  nests  are  found  lying  between  normal  uterine  glands  (natural 
size)  (Kelly). 

The  causation  of  cancer  of  the  uterus  is  as  undetermined,  with 
the  exception  of  one  factor,  as  is  the  causation  of  cancer  elsewhere.  That 
one  factor  is  laceration  of  the  cervix  from  labor.^  This  is  an  extremely 
important  matter,  and,  in  addition  to  others,  Craig "  has  pointed  out 
that  among  the  victims  of  uterine  cancer  it  is  almost  impossible  to  find 
one  who  has  suffered  from  a  cervical  laceration  which  has  been  early 
and  properly  repaired.     It  is  now  accepted  as  a  fact  among  observant 

1 1  have  referred  already  to  the  possibility  of  the  malignant  degeneration  of 
myomata. 

2  Daniel  H.  Craig,  New  York  Med.  Jour.,  July  S,  1905. 


308 


FEMALE  ORGANS  OF  GENERATION 


practitioners  that  laceration  of  the  cervix  is  a  common  cause  of  uterine 
cancer.  One  must  consider  also  the  age  of  the  patient — uterine  cancer 
is  rare  before  thirty-five  years,  and  is  most  common  between  forty  and 
fifty.     It  is  not  conimon  among  negroes. 

The  early  symptoms  of  cancer  of  the  uterus  are  elusive;  the  late  symp- 
toms are  flagrant.  The  subject  has  greatly  agitated  the  profession 
of  recent  3ears,  and  a  vigorous  propaganda  has  been  started  in  this 


B  I  a  «i  *^» 


Fie.  190. — Double  hydroureter  due  to  advanced  cancer  of  the  cervix  uteri  (H.  A. 

Kelly). 


country,  as  well  as  in  Germany,  to  inform  the  public  and  the  profession 
of  the  need  of  treating  cancer  early.  The  result  is  that  we  are  some- 
what improving  our  operative  statistics. 

It  has  been  commonly  taught  that  hemorrhage  is  the  first  symptom 
of  cancer  of  the  uterus.  This  is  not  true  always.  A  more  frequent 
symptom  is  a  thin,  clear,  watery  discharge,  followed  after  a  few  weeks 
by  persistent  and  increasing  leukorrhea.     Sometimes  pain  in  the  coccyx 


TUMORS  OF  THE   UTERUS  309 

is  the  first  symptom.  The  leukorrhea  is  clue  to  a  coincident  endometritis 
and  to  the  discharge  from  the  cancer  itself.  At  first  innocent  in  appear- 
ance, it  gradually  becomes  foul  and  rankly  offensive.  Hence  much  of 
the  horror  and  disgust  with  ^^'hich  the  disease  is  regarded. 

Hemorrhage  comes  from  the  base  of  the  cancer,  and  is  due  often  to 
some  slight  traumatism,  as  from  taking  a  vaginal  douche.  The  bleed- 
ing may  or  may  not  be  associated  with  menstruation.  It  usually  comes 
on  gradually,  a  little  at  a  time,  repeated  after  a  few  days  or  even  after 
months.  Then  it  becomes  a  persistent  ooze,  and  the  patient's  strength 
becomes  exhausted. 

Pain  is  quite  indefinite  in  freciuency  and  character;  when  present, 
it  is  referred  to  the  coccyx,  perineum,  or  thighs.  A  spread  of  the  cancer 
may  involve  other  organs  and  cause  abdominal  pains  of  various  sorts. 

Sundry  disorders  of  the  abdominal  viscera  appear  late — disorders 
of  the  kidneys,  intestines,  rectum,  ureters,  and  bladder — as  the  disease 
invades  those  several  parts. 

Of  course,  there  are  the  inevitable  cachexia,  wasting,  debility,  de- 
pression, and  loss  of  appetite,  with  the  dyspepsia  and  constipation  which 
we  see  in  nearly  all  cases  of  cancer. 

The  diagnosis  of  uterine  cancer  is  based  on  such  a  clinical  history  as 
I  have  described,  noting  especially  the  hemorrhage,  foul  discharge,  pain, 
and  late  cachexia ;  and  on  the  physical  signs,  which  are  ascertained  by 
bimanual  examination  and  by  inspection  through  the  speculum.  In- 
spection and  palpation  of  the  cervix  are  easy,  but  sometimes  it  is 
important  to  excise  a  bit  of  suspicious  growth  in  order  to  confirm  the 
diagnosis  by  microscopic  examination.  Scrapings  are  of  little  value 
for  microscopic  purposes.  The  diagnosis  of  cancer  of  the  body  of  the 
uterus  is  more  difficult  than  is  the  diagnosis  of  cancer  of  the  cervix, 
and  may  be  impossible.  Says  Dudley:  "  Frequently  recurring  glandu- 
lar, h3'perplastic  endometritis,  with  much  cystic  development  after 
repeated  curetage,  especially  if  associated  with  free  hemorrhage  and 
a  watery  discharge,  should  give  rise  to  grave  apprehension,  and  would 
justify  the  removal  of  the  uterus  on  suspicion."  In  advanced  cancer 
of  the  body  of  the  uterus  one  finds  that  organ  considerably  enlarged, 
hard,  nodular,  and  more  or  less  fixed,  with  edema  of  the  legs,  involve- 
ment of  the  glands  of  the  groin  and  abdomen,  and  evidence  of  such 
complicating  abdominal  disorders  as  I  have  described. 

Cancer  of  the  uterus  must  be  distinguished  from  myoma,  sarcoma, 
retained  placental  tissue,  incomplete  abortion,  hypertrophy  of  the  cer- 
vix, endometritis,  syphilis,  chronic  metritis,  ichthyosis,  tuberculosis, 
laceration  of  the  cervix,  and  subinvolution  of  the  uterus. 

Treatment  of  cancer  of  the  uterus  is  paUiative  or  radical,  and  radical 
treatment,  like  radical  treatment  of  stomach  cancer,  is  to  be  undertaken 
doubtfully  and  after  a  full  understanding  with  the  patient  or  her  friends. 
There  is  no  manner  of  doubt  that  early  cancer  of  the  body  of  the  uterus 
and  many  cancers  of  the  cervix  may  be  removed  successfully  and  per- 
manentlj';  but  we  can  never  promise  a  cure.  There  are  other  reasons, 
however,  for  advising  operation:  there  is  always  the  chance  of  cure; 


310 


FEMALE  ORGANS  OF  GENERATION 


there  is  a  fair  assurance  of  relief  from  suffering,  and  the  abolishment  of 
the  foul  discharge,  with  the  possibility  of  prolonging  life.  Moreover, 
a  sense  of  having  something  done  is  a  great  stimulus  to  many  i)atients. 
Above  all  things,  it  is  the  tluty  of  every  practitioner  to  preach  tiie  gospel 
that  cancer  of  the  uterus  is  not  ahvays  an  incurable  disease,  especially 
when  treated  early. 

Palliative  operations  on  the  uterus  are  undertaken  to  relieve  pain 
and  check  the  foul  discharge  for  a  time  at  least.  The  best  palliative 
measures  are  a  thorough  cureting  and  cauterization  with  the  Paciuelin 
cautery. 

There  are  two  imjjoitant  radical  operations  for  uterine  cancer: 
vaginal  h}'sterectomy  and  abdominal  hysterectomy.  The  old-time 
high  amputation  of  the  cervix  is  not  a  radical  operation. 


Fig.  191. — Vaginal  hysterectomy — step  1  (adapted  from  Dudley). 

Vaginal  Hysterectomy. — This  operation  has  long  been  popular  and 
has  a  relatively  low  mortality.  It  never  insures  a  cure,  even  when  per- 
formed earl}^  in  the  disease,  but  the  statistics  of  many  operators  show 
that  it  docs  sometimes  cure.  These  statistics  are  so  variable  that  they 
are  hardly  worth  quoting.  They  show  us  that  from  10  to  60  per  cent, 
of  all  cases  are  well  three  years  after  the  operation. 

In  the  detail  of  the  technic  of  vaginal  hysterectomy  two  methods  are 
advocated — hemostasis  by  forcipressure  (clamping  the  broad  ligaments 
and  leaving  the  clamps  in  place)  and  hemostasis  by  ligature.  I  advocate 
the  latter,  as  it  is  cleaner,  is  better  surgery,  and  causes  far  less  pain  to  the 
patient  after  her  recovery  from  ether.     The  steps  of  the  operation  are 


TUMORS^   OF   THI<:    UTERUS 


311 


well  illustrated  by  the  diajiranis.  and  l)riefly  are  as  follows.     With  the 
patient  in  the  lithotomy  position,  and  with  a  strong  hght  and  plenty  of 


Fig.  192. — Vaginal  hysterectomy — step  2. 


Fig.  193. — Vaginal  hysterectomy— step  3. 


assistance,  the  surgeon  holds  widely  retracted  the  vaginal  outlet.     He 
seizes  the  cervLx,  after  having  cureted  and  cauterized  obvious  protruding 


312 


FEMALE  ORGANS  OF  GENERATION 


Fig.  194. — Vaginal  liysterectomy — step  4  (adapted  from  Dudley). 


Fig.  195. — Vaginal  hysterectomy — step  r>  iadapt(>d  from  Dudley). 


TUMORS  OF  THE   UTERUS 


313 


disease,  stitches  up  firmly  the  os,  to  prevent  fouling  of  the  wound  by- 
discharges,  and  with  flat  vulsellum  forceps  draws  the  cervix  to  the 
vulva.  With  scissors  or  knife  he  then  incises  the  vaginal  mucosa  about 
the  cervix  and  strips  it  back  thoroughly  on  all  sides  for  an  inch  or  more, 
when  the  uteroperitoneal  reflection  will  be  recognized  by  the  loose 
character  of  the  tissues,  and  by  the  fact  that  under  the  finger  the  loose 
tissue  slips  over  the  peritoneum.  The  stripping  back  should  be  done 
with  the  finger.  The  operator  then  seizes  with  forceps  the  postperi- 
toneal  fold,  which  has  been  stripped  loose  from  the  rectum,  and  nicks 
through  into  Douglas'  fossa.     He  enlarges  this  opening  by  tearing  with 


L   ..  - .  -A- 

Fig.  196. — Vaginal  hysterectomy — step  6  (adapted  from  Dudley). 

the  fingers.  Then  he  opens  anteriorly  between  the  cervix  and  bladder 
in  the  same  fashion. 

With  wide  openings  before  and  behind  the  uterus  the  surgeon  is  now 
ready  to  control  the  blood-suppty.  In  suitable  cases  this  may  be  done 
readily  by  passing  the  forefinger  of  the  left  hand  up  through  the  poster- 
ior opening  and  hooking  down  first  the  left  and  then  the  right  broad 
ligament.  Secure  the  ligaments  with  stout  silk  sutures,  embracing  first 
the  ovarian  artery,  then  the  uterine  artery,  and  then,  behind  these 
ligatures,  the  broad  ligament  itself  en  masse. 

Having  secured  the  vessels,  cut  away  the  broad  ligament  close  to  the 
uterus.     Some  surgeons,  after  cutting  away  the  left  broad  ligament 


314 


FEMALE  ORGANS  OF  GENERATION 


drag  down  the  fundus  through  the  left  opening,  and  thus  put  the  right 
broad  ligament  on  the  stretch,  when  it  may  readily  be  secured  and  cui 
away  with  the  parts  practically  outside  of  the  vulva. 

The  uterus  having  been  removed  in  this  fashion,  stitch  up  the  jjeri- 
toneum,  bringing  together  the  divided  round  ligament  and  broad  liga- 
ment stumps,  and  then  sew  up  the  rent  in  the  vagina.  Drainage  may 
be  supplied  by  passing  a  gauze  wick  into  the  subperitoneal  space  through 
a  small  opening  in  the  vaginal  vault.  These  manipulations  are  facili- 
tated by  having  the  patient  in  a  motlified  Trendelenburg  position. 


Fig.  197. — \'aginal  iu-sterectomy — step  i  (adapted  from  Dudley). 

There  are  certain  dangers,  difficulties,  and  complications  in  vaginal 
hysterectomy.  The  operation  should  not  be  undertaken  in  the  face  of 
involvement  of  the  para-uterine  structures — when  the  uterus  is  in  any 
degree  fixed,  when  the  broad  ligaments  are  thickened,  when  the  tubes 
and  ovaries  are  diseased,  and  when  the  lymphatic  connections  and  glands 
are  involved.  It  is  by  no  means  easy  always  to  avoid  injuring  the 
ureters;  the}'  have  often  been  cut  by  experienced  operators  even.  They 
may  be  avoided  by  introducing  catheters  into  them,  and  b}'  clinging 
closely  to  the  cervix  in  making  the  dissection. 

We  are  as  yet  far  from  being  able  to  remove  the  utenis  through  the 
vagina  with  such  ease  and  clearness  of  vision,  looking  to  lymphatic 
involvements,  as  in  removing  the  breast  and  its  associated  lymph-nodes. 


TUMORS   OF  THE    UTERUS 


315 


The  presence  of  the  ureters,  lying  within  one-half  inch  of  the  cervix, 
renders  almost  impossible  a  wide  and  sure  dissection  by  the  vaginal 
route.  In  spite  of  these  facts  the  vaginal  route  will  always  be  a  favorite 
route  with  operators,  because  in  early  cases  the  dissection  is  easy,  the 
oiKM-ative  mortality  low,  the  immediate  results  briUiant,  convalescence 
short,  discomfort  slight,  and  recurrence  reasonably  infrequent. 

Abdominal  Hysterectomy  for  Cancer. — This  operation  is  shown  by 
statistics  to  be  more  fatal  than  vaginal  hj^sterectomy,  but  such  statistics 
are  misleading,  because  abdominal  hysterectomy  is  extremely  difficult 
or  impossible  in  the  case  of  fat  women,  whose  thick  abdominal  walls 
and  densely  packed  pelves  render  manipulations  difficult  or  impossible. 


Fig.  198. — Vaginal  hysterectomy — step  8  (adapted  from  Dudley). 

Moreover,  abdominal  hysterectomy  is  commonly  practised  in  the  more 
advanced  and  complicated  cases. 

The  development  of  abdominal  hysterectomy  for  cancer  of  the  uterus 
has  been  stimulated  latel5\  in  this  countr}-  especially,  by  the  researches, 
practice,  and  preaching  of  John  A.  Sampson,^  but  his  extremely  inter- 
esting and  radical  operation  has  not  yet  found  entire  favor  with  the 
profession,  on  account  of  the  difficulty  of  following  his  technic  without 
a- resulting  high  mortality.  I  am  convinced,  however,  that  a  more 
frequent  resort  to  a  modified,  but  still  radical,  abdominal  hysterectomy 
for  cancer  of  the  uterus  will  result  in  improving  our  statistics. 

1  John  A.  Sampson,  Jour.  Amer.  Med.  Assoc,  October  29,  1904;  ibid..  May  20, 
1905. 


316 


FEMALE  ORGANS  OF  GENERATION 


The  Operation. — With  the  patient  well  elevated  in  Trendelenburg's 
position  and  the  intestines  carefully  isolated  (the  maneuver  of  stitching 
the  parietal  peritoneum  to  the  posterior  pelvic  brim  gives  a  particularly 
clear  and  free  fieldj,  the  uterus  is  removed  in  nmcli  the  same  fashion  as  I 
stated  in  describing  panhysterectomy  for  myoma — the  vaginal  vault 
having  previously  been  opened  from  below,  if  you  choose.  The  broad 
ligaments  may  then  be  extensively  dissected ;  the  retroperitoneal  space 
laid  open  by  splitting  the  broad  ligaments;  the  ureters,  iliac  vessels,  and 
lymphatics  exposed,  and  all  suspicious  tissue  removed  by  careful  knife 


Fig.  199. — Abdominal  hysterectomy  for  cancer.  The  uterus  fF)  being  pulled 
far  to  the  right,  the  uterine  artery  is  tied  and  dissected  away  from  the  ureter  (Ur) 
with  a  mass  of  pelvic  cellular  tissue.  P  is  a  posterior  layer  of  peritoneum;  B,  the 
bladder;  C,  the  cervix;  V,  the  vagina  fKelly,  after  J.  G.  Clark). 

and  gauze  dissection.^  It  will  not  do  to  remove  too  thoroughly  all  the 
tissues  about  the  ureters,  because  .such  removal  results  in  cutting  off  their 
blood-supply,  and  in  consequent  necrosis  of  the  ureters.  In  case  of 
the  ureters  being  involved  in  the  growth  or  necessarily  denuded,  they 
must  be  resected  and  implanted  into  the  bladder. 

The  simpler  abdominal  hysterectomy  may  be  no  more  effective  for 
a  cure   than  is  vaginal  hysterectomy;  but  abdominal  hysterectomy 

1  The  reader  should  supplement  this  brief  description  by  studying  Sampson's 
admirable  articles. 


TUMORS   OF  THE    UTERUS 


317 


does  permit  a  more  careful  exploration  of  the  field.  Whether  or  not 
the  extensive  dissections  I  have  last  indicated  shall  prove  of  permanent 
usefulness  remains  to  be  demonstrated  through  time  and  experience. 

The  after-treatment  of  these  cases,  as  well  as  the  after-treatment 
of  cases  of  vaginal  hysterectomy,  differs  in  no  essential  from  that  fol- 
lowed in  cases  of  myoma. ^ 


Vagocuffj 


Fig.  200. — Panhysterectomy  for  cancer.  Epithelioma  of  the  cervix  in  grape- 
like mass.  Showing  the  extensive  removal  of  the  uterus  and  the  broad  ligaments 
by  the  abdominal  method  (J  natural  size)  (Kelly). 

There  are  sundry  other  diseases  and  tumors  of  the  uterus,  more  or  less 
rare  and  more  or  less  unimportant,  which  it  behooves  us  to  mention  in 
passing. 

Endothelioma 

Endothelioma  is  a  malignant  tumor  rising  from  the  endothelium  of 
the  vessels  or  serous  surfaces  and  closely  resembling  cancer.  It  is  found 
in  the  fundus  of  the  uterus  as  well  as  in  the  cervix,  and  may  extend  to 
neighboring  organs.  The  course,  symptoms,  and  treatment  are  similar 
to  those  of  cancer. 

Sarcoma 

Sarcoma  is  rare  in  the  uterus ;  it  may  develop  in  youth,  in  maturity, 
or  in  old  age.  Three  forms  are  described:  (1)  Fibrosarcoma;  (2)  diffuse 
sarcoma;  (3)  racemose,  grape-like  sarcoma. 

Fibrosarcoma  resembles  myoma  in  its  location,  though  it  is  encapsu- 
lated rarely.  Diffuse  sarcoma  may  occur  anywhere  in  the  uterus,  and 
is  wont  to  invade  the  whole  organ.  Racemose  is  very  rare;  it  generally 
starts  in  the  cervix,  and  forms  cyst-like  masses  resembling  hydatids. 
It  has  been  found  in  children  as  well  as  in  adults.  It  grows  rapidly  and 
is  extremely  malignant. 

1  For  a  suggestion  for  the  palliative  treatment  of  uterine  cancer  see  foot-note  on 
p.  848. 


318  FEMALE  ORGANS  OF  GENERATION 

Sarcomatous  degeneration  of  a  myoma  may  occur  (spindle-cell 
sarcoma).  One  suspects  it  when  hemorrhage  from  myoma  increases; 
when  the  tumor  grows  after  the  menopause;  when  the  growth  returns 
after  removal;  when  ascites  develops  suddenly;  when  cachexia  appears 
rapidly.  The  symptoms  of  the  various  forms  of  sarcoma  are  in  no  way 
peculiar.  Some  of  the  sarcomata  grow  slowly;  some  are  extremely 
malignant.  Spindle-cell  sarcoma,  for  instance,  may  not  destroy  life 
for  many  years ;  on  the  other  hand,  the  diffuse,  small,  round-cell  sarcoma 
is  more  malignant  than  is  cancer.  All  the  forms  suggest  cancer,  symp- 
tomatically,  but  metastases  are  more  numerous  and  more  distant  often 
than  is  the  case  with  cancer,  for  the  emboli  of  sarcoma  travel  by  the 
veins,  while  cancer  progresses  through  the  lymphatics. 

The  treatment  of  sarcoma  is  the  same  as  that  of  cancer.  Indeed,  it 
rarely  happens  that  the  two  are  distinguished  from  each  other  before 
operation. 

Deciduoma  Malignum 

Deciduoma  malignum  (choriodeciduoma)  is  an  excessively  fatal 
tumor  resembling  sarcoma.  It  is  often  preceded  by  hydatidiform  mole, 
and  occurs  commonly  between  the  ages  of  twenty  and  forty.  It  was 
described  so  lately  as  1889  only.^ 

The  growth  is  unique,  the  essential  element  being  a  large  giant-cell 
embedded  in  sarcoma-like  substance.     But  the  tumor  is  epithelial. 

The  growth  appears  as  more  or  less  circumscribed,  dirty  reddish 
brown,  and  friable,  with  frequent  early  metastases. 

The  symptoms  suggest  cancer,  but  the  most  characteristic  symptom 
is  a  profuse  hemorrhage  occurring  after  labor  or  abortion.  There  is  an 
abundant  foul,  watery  or  bloody  discharge,  often  containing  hydatid- 
like  moles.  There  are,  of  course,  the  usual  constitutional  disturbances 
which  we  associate  with  malignant  disease. 

On  examination  one  finds  an  enlarged  uterus,  movable  or  fixed, 
smooth  or  nodular.  Often  the  uterine  cavity  will  admit  the  finger, 
which  detects  masses  of  soft  tissue  and  clots.  One  settles  the  diagnosis 
by  the  microscope. 

Nearly  80  per  cent,  of  all  patients  affected  with  choriodeciduoma 
die  within  six  months. 

The  only  possibility  of  cure  rests  in  prompt  hysterectomy. 

In  this  chapter  I  have  sketched  in  brief  outline  the  common  sur- 
gical diseases  and  injuries  of  the  uterus.  I  have  given  such  a  picture  as 
is  familiar  to  the  general  surgeon — a  picture  which  may  help  to  guide 
the  studies  of  the  undergraduate  and  the  practice  of  the  physician. 
The  numerous  comprehensive  text-books  and  systems  of  gynecology 
are  essential  to  a  wide  understanding  of  these  matters. 
1  Sanger,  A  System  of  Gynecology,  Play  fair. 


CHAPTER  XI 

FALLOPIAN  TUBES  AND  OVARIES 

Disease  of  the  uterus  is  often  associated  with  disease  of  the  tubes 
and  ovaries,  as  I  stated  in  the  hist  chapter.  This  association  is  notably- 
true  when  injiammations  of  the  organs  are  concerned,  but  it  is  a  signifi- 
cant fact  that  any  disease  of  the  uterus  may  be  found  associated  with 
some  disease  of  its  adnexa,  even  though  the  nature  of  the  disease  of  the 
adnexa  be  something  quite  other  than  what  is  found  in  the  uteiiis.  Thus 
uterine  m3'omata  may  coexist  with  ovarian  cysts,  and  soKd  tumors  of 
the  ovar}^  may  be  associated  with  uterine  displacement  and  endome- 
tritis.    Cause  and  effect  are  often  sufficiently  obvious. 

We  shall  consider  inflammations  of  the  adnexa  and  structures 
surrounding  the  uterus,  solid  tumors  and  cysts  of  the  adnexa,  and  ex- 
tra-uterine pregnancy. 

SALPINGITIS 

Salpingitis^  is  inflammation  of  the  Fallopian  tubes.  The  anatomy  of 
the  Fallopian  tubes  is  interesting,  and  their  development  especially  is 
interesting.  They  are  formed  by  that  part  of  Midler's  ducts  above 
the  round  ligaments.  The  uterus  and  vagina  are  formed  from  that  part 
of  the  ducts  below  the  round  ligaments,  together  with  the  Wolffian 
ducts.  The  various  uterine  structures,  mucosa,  muscularis,  and  peri- 
toneum are  continued  to  the  tubes,  so  that  we  have  an  endosalpinx, 
a  myosalpinx,  and  a  perisalpinx.  The  tubes  spring  from  the  horns  of 
the  uterus,  and  lie  in  the  upper  portion  of  the  broad  ligaments,  being 
from  3  to  5  inches  long.  Their  lengi:h  is  divided  into  an  isthmus,  an 
ampulla,  and  a  fimbriated  extremity. 

The  causation  of  salpingitis  has  been  already  sketched  in  our  last 
chapter,  when  we  described  inflammations  of  the  uterus.  By  far  the 
greatest  number  of  tubes  involved  in  inflammation  are  infected  from 
below,  and  the  causes  are  the  common  causes  of  metritis — abortion, 
labor,  instrumentation,  gonorrhea,  syphilis,  tuberculosis.  The  writers 
discuss  other  causes  also,  among  which  appendicitis  is  important,  and 
the  acute  exanthemata,  various  constitutional  disorders,  and  the  spread- 
ing of  infection  from  other  organs.  Trauma — from  a  fall — cannot  cause 
a  salpingitis,  though  it  may  aggravate  an  already  existing  salpingitis. 

There  are  various  terms  used  by  writers,  and  Dudley  gives  the  fol- 
lowing classification : 

"  L  Catarrhal  salpingitis — salpingitis  serosa. 

"  2.  Purulent  salpingitis — salpingitis  pumlenta. 

1  Salpinx,  a  tube. 

319 


320  FEMALE  ORGANS  OF  GENERATION 

"  Catarrhal  salpingitis  may  result  in  sactosalpinx  serosa — hydro- 
salpinx. 

"  Purulent  salpingitis  may  result  in  sactosalpinx  jjuiulcnta — 
pyosalpinx. 

"If  sactosalpinx  is  complicated  by  hemorrhage  into  the  tube,  it  is 
called  sactosalpinx  ha^morrhagica,  or  hematosalpinx;  this  is  more  com- 
mon in  serous  than  in  purulent  infections."  Then  there  is  tuberculous 
salpingitis. 

The  pathology  of  these  various  conditions  is  similar  often,  and  the 
conditions  themselves  frequently  are  impossible  to  differentiate  clinic- 
all3^  The  infecting  medium  usually  reaches  the  tube  through  the  canal 
of  the  uterus,  though  tuberculosis  may  be  implanted  from  above  or  by 
the  blood-stream.  The  usual  phenomena  of  inflammation  take  place 
after  infection  has  occurred — such  phenomena  as  are  seen  in  metritis; 
but  the  results  are  different,  because  in  the  case  of  the  uterus  there  is 
usually  fair  drainage,  while  in  the  case  of  the  tube  the  isthmus  frequently 
becomes  choked  or  closed  completely.  The  fimbriated  end  of  the  in- 
flamed tube  may  remain  open,  but  generally  it  becomes  closed  also. 
When  the  fimbriated  end  remains  open,  tubal  secretions  flow  out  and 
infect  the  neighboring  peritoneum  and  the  epithelial  covering  of  the 
ovary;  so  that  if  there  be  present  a  freshly  ruptured  Graafian  follicle, 
ovaritis  may  result.  Again,  infection  may  penetrate  the  wall  of  the 
tube,  even  when  the  fimbriated  end  is  closed.  In  this  case  a  perisal- 
pingitis may  arise  with  involvement  of  all  the  pelvic  \'iscera.  A  Fal- 
lopian tube  highly  inflamed  is  somewhat  analogous  to  an  inflamed 
appendix,  and  acute  salpingitis  is  in  some  degree  similar  to  acute  ap- 
pendicitis—not so  deadly,  however,  because  the  tube  is  a  stronger  organ 
than  the  appendix,  its  infections  are  less  vimlent,  as  a  rule,  and  walling- 
off  processes  are  more  certain.  In  advanced  salpingitis,  however,  we 
do  get  tubal  perforation,  peritonitis  more  or  less  extensive,  adhesions, 
multiple  pus-cavities,  and,  frequently,  a  thick,  matted,  angry  mass  of 
viscera,  packing  tightly  the  pelvis,  apparently  impossible  of  unravel- 
ment. 

This  condition  of  inflammatory  involvement  of  the  pelvic  contents 
was  commonly  called  pelvic  cellulitis,  for  it  was  thought  that  the  in- 
flammation centered  in  the  loose  connective  tissue  about  the  sides  of  the 
pelvis,  and  in  the  broad  ligaments  and  para-uterine  structures,  and  that 
the  tube,  when  involved,  was  involved  secondarily.  Doubtless  the 
term  pelvic  cellulitis  is  proper  enough  under  certain  conditions,  but  most 
pathologists  now  agree  that  extensive  inflammation  of  the  pelvic  viscera 
is  commonly  secondary  to  tubal  inflammation.  Pelvic  cellulitis  lead- 
ing to  salpingitis  even  does  occur  sometimes,  through  direct  transmission 
of  infection  from  the  uterus,  by  means  of  lymphatic  and  venous  channels. 
When  this  happens,  there  results,  first,  a  perimetritis  with  inflammation 
extending  into  the  adjacent  viscera  until  eventually  there  is  produced  a 
condition  similar  to  that  which  originates  in  a  salpingitis.  Clinically, 
however,  one  may  often  make  this  distinction,  that  whereas  an  extensive 
inflammation  originating  in  the  tube  centers  there,  is  there  most  destmct- 


SALPINGITIS 


321 


ive,  and  spreads  from  that  focus,  a  pelvic  cellulitis,  on  the  other  hand, 
originating  in  the  uterus,  involves  that  organ  primarily,  submits  it  to 
more  or  less  destructive  processes,  causes  para-uterine  inflammation 
and  abscess  formation,  and  involves  the  tubes  secondarily  only.  This 
distinction  may  have  an  important  bearing  upon  prognosis  and  upon 
treatment,  for  a  primary  salpingitis  calls  for  treatment  of  the  tubes 


Fig.  201. — Matting  of  the  viscera  in  salpingitis. 


directly,  while  a  pelvic  cellulitis  may  necessitate  more  particularly  the 
treatment  of  the  uterus  and  the  deep  pelvic  tissues.  In  the  one  case  it 
may  be  proper  to  operate  upon  the  tubes  through  abdominal  section. 
In  the  other  case  it  may  be  essential  to  drain  a  pelvic  abscess  through 
vaginal  section.  But  bear  in  mind  always  that  the  two  varieties  of 
inflammation  may  eventuate  in  producing  similar  appearances  and  may 
necessitate  similar  methods  of  treatment. 

21 


322 


FEMALE  ORGANS  OF  GENERATION 


Hitherto  we  have  been  considering  the  nioie  virulent  forms  of  in- 
flammation. There  are  the  milder  forms,  catarrhal  salpingitis,  resulting 
in  hytlrosalpinx  and  rarely  in  hematosalpinx.  In  these  milder  forms 
the  inflammation  remains  confined  to  the  tube. 

The  tube  and  ovary  may  be  involved  simultaneously  in  disease. 
For  instance,  we  see  the  conditions  known  as  tubo-ovarian  cyst  and 
tubo-ovarian  abscess.  Such  conditions  are  brought  about  through  the 
formation  of  inflammatory  adhesions  between  the  tubes  and  ovaries, 
a  resulting  sinus  formation  from  one  organ  to  the  other,  and  the  partici- 
pation of  each  in  the  disease  of  the  other.  As  a  rule,  inflammation  of 
the  ovaries  is  secondary  to  inflammation  of  the  tubes;  but  ovaritis  may 
occur  independently  of  salpingitis,  through  infection,  by  means  of  the 


Fig.  202. — Tubo-ovarian  cyst.  The  tube  above  ends  in  a  bulbous  extremity 
fused  with  the  ovary,  with  only  a  slight  sulcus  between  them.  The  ovarian  ligament 
is  shown  below,  leading  out  to  the  cystic  ovary  (path.  No.  665.,  natural  size)  (H.  A. 
Kelly). 


lymph-  and  blood-channels  from  the  uterus  or  from  other  organs, 
among  which  organs  the  inflamed  appendix  is  the  most  common  source 
of  infection.  The  exciting  organisms  in  the  case  of  ovaritis  are  the 
gonococcus,  the  colon  bacillus,  the  staphylococcus,  the  streptococcus,  the 
pneumococcus,  the  typhoid  bacillus,  and  the  tubercle  bacillus.  A 
true  primary  ovaritis  is  extremely  rare. 

Symptoms  of  Salpingitis. — It  is  often  impossible  to  distinguish 
the  symptoms  of  salpingitis  from  those  of  ovaritis,  especially  when  the 
ovaritis  is  a  consequence  of  the  salpingitis.  Ovaritis  due  to  other 
causes  frequently  may  be  distingviished.  However,  whether  or  not  the 
inflammation  involve  the  ovary,  you  will  find  the  sufferer  from  salpingitis 
complaining  of  pain,  dull  or  Ijurning,  constant  or  remitting,  and  of 
localized  tenderness.     There  may  or  may  not  be  recurring  rises  of  temr 


SAI-nXGITIS 


323 


peratiuc,  for  that  depends  largely  on  the  involvement  of  the  peri- 
toneum. Ivxcept  for  the  fact  that  the  focus  of  infection  is  in  the  pelvis, 
the  sym|)toms  suggest  strongly  those  of  appendicitis.  Moreover,  it  is 
often  impossible  to  distinguish  sharply  an  acute  salpingitis  from  a 
chronic  salpingitis,  since  the  two  constantly  run  into  each  other.  A 
chronic  salpingitis  may  become  acute  at  any  time,  just  as  an  acute 
salpingitis  may  become  chronic,  and  in  most  cases  one  looks  for  some 
s^'mptoms  of  involvement  of  the  uterus,  such  as  I  described  in  Chapter  X. 


Fig.  203. — Tuberculous  salpingitis.  The  right  tube  and  ovary  divided,  showing 
the  extent  of  the  disease  in  the  ovary  and  in  the  numerous  cross-sections  of  the 
tube.  F.U  is  the  fundus  of  the  uterus,  and  Ma  myoma  attached  to  it.  Between 
the  uterus  and  tb.e  myoma  is  seen  a  portion  of  a  large  sac  of  an  encysted  peritonitis. 
The  left  tube  is  distended,  convolute,  and  covered  with  tubercles;  the  fimbriated  end 
is  swollen  and  exhibits  numerous  tubercles.  This  is  preeminently  a  case  for  extir- 
pation of  tubes,  ovaries,  and  uterus.  (Case  of  Dr.  C.  Cone,  JMms  Hopkins  Hosp. 
Bull.,  May,  1897,  |-  natural  size.— CuU en.) 


On  physical  examination,  which  should  be  made  bimanually,  great 
varieties  of  conditions  are  found.  The  finger  should  explore  both  the 
vagina  and  the  rectum,  when  one  ma}^  discover  all  sorts  of  pelvic  masses, 
from  a  merely  thickened  tube  and  broad  ligament  to  a  fixed  and  enlarged 
uterus,  a  collection  of  exudate  filling  the  pelvis,  fluctuating  areas,  and 
hard,  porky,  or  brawny  tumors.  Often  it  is  impossible  to  differentiate 
the  component  parts  of  this  collection,  or  again  one  may  distinguish 
satisfactorily  the  uterus  from  the  tube,  and  the  tube  from  the  ovary, 
and  may  map  out  collections  of  pus. 

The  diagnosis  of  chronic  salpingitis  is  founded  upon  such  a  his- 
tory, symptoms,  and  physical  signs  as  I  have  described — commonly 


324 


FEMALE  ORGANS  OF  GENERATION 


there  is  an  old  p;()n()rrhca,  iiuule  evident  perhaj);^  by  the  eontinuance  oi 
a  chronieally  (enlarged  vulvovaginal  gland;  there  is  the  story  of  long- 
continued  uteiine  discharges,  sterility,  dysmenorrhea,  a  sense  of  weight, 
bearing  down,  tenderness,  faihng  health,  and  invalidism.  Such  a 
composite  picture  may  have  been  put  together  within  a  few  days  or 
weeks,  and  may  have  been  associated  with  previously  acute  symptoms 
suggesting  apjx^ndicitis.  In  the  acute  cases  one  fre(iuently  learns  of  a 
recent  abortion  or  labor.     Or  the  stoiy  may  mn  over  weeks  or  months, 

in  which  case  one  is  apt  to  suspect 
rather  a  gonorrheal  infection.  All 
forms  of  infection  may  involve  all 
the  pelvic  organs,  and  may  result 
in  similar  pathologic  appearances; 
but  the  puerperal  infections,  though 
frequently  chronic,  may  run  an 
acute  and  fatal  course  even,  while 
the  gonorrheal  affections  are  those 
usually  followed  by  chronic  disease. 
When  all  is  said,  however,  the  sur- 
geon frequently  is  surprised  on  oper- 
ating to  see  very  extensive  struc- 
tural changes  out  of  all  proportion 
to  the  trifling  symptoms. 

Tuberculous  salpingitis  is  not 
always  distinguisha'ble  from  the 
forms  I  have  described.  Between 
6  and  8  per  cent,  of  all  tubal  infec- 
tions are  tuberculous.  The  involve- 
ment of  the  tubes  may  be  primary 
or  secondary,  and  is  often  a  part 
of  a  general  tuberculous  peritonitis. 
Tuberculous  salpingitis  also  may  be 
chronic  or  acute.  When  it  is  acute, 
the  secretions  escape  usually  through 
the  fimbriated  end  of  the  tube, 
which  is  open  frequently  in   acute 

T-.     ^^ .     rr,,     ^ ,   1  forms.     Chronic    salpingitis  is  con- 

Fig.  204. — The  T-tube.  g      ^      -^-u-  ^        i\   ? 

fined  withm  a  closed  tube. 

The  diagnosis  of  tuberculous  salpingitis  is  almost  impossible  of  differ- 
entiation clinically  from  other  forms  of  salpingitis,  though  in  typical 
cases  of  chronic  tuberculous  salpingitis  one  finds  loss  of  weight,  a  hectic 
temperature,  a  rapid  pulse,  frequent  amenorrhea,  an  abdomen  little  if 
at  all  sensitive  to  pressure,  sometimes  ascites;  and  one  looks  for  a  history 
of  tuberculosis  and  the  involvement  of  other  abdominal  organs. 

The  treatment  of  all  these  pelvic  infections  is  divided  into  medical 
and  operative  treatment.  I  shall  not  discuss  the  former  further  than 
to  say  that  it  consists  in  improved  hygiene,  an  out-of-doors  life,  rest, 
carefvil   feeding,   tonics,   ichthyol   suppositories    (an  extremely  useful 


SALPINGITIS 


325 


measure),  hot  packs,  hot  douches,  tampons,  and,  in  the  hands  of  some 
physicians,  pc'lvic  massage. 

The  operative  treatment  of  acute  salpingitis  presents  questions  for 
careful  judgment.  The  answer  to  the  question,  when  to  operate,  is  not 
so  easy  as  we  found  it  in  the  case  of  acute  appendicitis.  We  can  lay 
down  no  rule  that  an  inflamed  tube  should  be  removed  at  once,  as  we 
should  say  of  an  acutely  inflamed  appendix.  An  acutely  inflamed  tube 
rarely  threatens  life  immediately.  The  inflammatory  process  is  relatively 
slow,  and  the  formation  of  protecting  adhesions  is  almost  certain.  In 
a  great  majority  of  these  cases  rest,  douching,  and  cold  applications  will 
relieve  the  symptoms  and  localize  the  process,  so  that  a  delayed  oper- 
ation, if  any,  may  be  anticipated.  Rarely  one  sees  fulminating  peri- 
tonitis from  an  acutely  inflamed  tube. 

On  the  other  hand,  with  the  subsidence  of  acute  symptoms  and  with 
the  establishment  of  a  chronic  salpingitis  one  finds  often  that  non-opera- 
tive treatment  fails  to  cure. 

Operative  treatmerU  of  salpingitis  is  undertaken  by  two  routes— the 
vaginal  and  the  abdominal;  and  the  old  discussion  as  to  choice  still  waxes 
and  wanes.  Without  entering  into  the  controversy  I  prefer  to  state  that 
my  own  practice  is  to  approach  the  disease  through  the  vagina  when 
pus-sacs  are  to  be  drained— especially  pus-sacs  which  present  m  the 
vagina.  The  operation  is  not  difficult.  With  the  patient  m  the  lith- 
otomy position  and  the  vaginal  canal  widely  exposed,  the  surgeon  mcises 
Douglas's  pouch  behind  the  cervix,  where  pus  usually  collects;  intro- 
duces his  finger,  explores  the  cavity,  evacuates  the  pus,  and  drains  with  a 
T-shaped  rubber  tube.  This  operation  takes  no  account  of  the  more 
radical  procedures  sometimes  advocated— the  breaking  up  of  adhesions, 
the  opening  of  the  general  peritoneal  cavity,  the  search  for  and  the 
bringing  down  and  packing  of  isolated,  distended  tubes,  and  the  re- 
moval of  organs.  In  any  vaginal  operation  for  drainage  the  surgeon 
should  avoid  injuring  the  ureters. 

Effective  drainage  is  established  by  the  operation  I  have_ described, 
and  in  nearly  all  cases  subsidence  of  inflammation  follows,  with  reason- 
ably prompt  healing.  The  cavity  should  be  washed  out  daily,  and 
should  be  kept  open  with  a  gauze  drain  after  the  first  week— so  long  as 
the  discharge  continues.  Inflamed  tubes  and  ovaries  are  not  removed 
by  these  measures,  but  it  is  astonishing  often  to  observe  m  how  short  a 
time  exudates  and  masses  will  disappear,  until  the  pelvis  is  returned  to  a 
nearly  normal  condition.  Later,  if  distorted  and  crippled  organs  remain 
the  surgeon  may  think  it  wise  to  open  the  belly  from  above  and  deal  with 
those  organs  by  the  abdominal  route.  Often  at  such  a  secondary  opera- 
tion he  will  be  surprised  to  find  the  remaining  structural  changes  ex- 
tremely slight.  ,  ^r^„lo7. 
Abdominal  section  for  pelvic  inflammation  was  an  extremely  popular 
procedure  a  few  years  ago.  We  now  employ  it  more  mtel  igently  and  m 
selected  cases-in  cases  of  chronic  salpingitis,  rather,  of  long  standing 
and  indolent  inflammations;  of  extensive  involvement  of  organs,  witn 
their  matting,  crippling,  and  disorganization.     The  operation  may  be 


326 


FEMALE  OKOAXS  OF  GEN'KRATION 


easy,  or  long,  difficult,  and  dangerous.  It  is  a  simple  matter  to  remove 
an  isolated,  thickened,  functionless  tube.  It  is  far  from  simple  to  clean 
up  and  set  right  a  pelvis  filled  with  dcnscl}-  matted  masses  of  viscera. 
For  the  sake  of  clearness  I  shall  describe  an  easy  operation — the  removal 
of  an  inflamed  tube,  without  complications.  I  shall  then  describe  a 
difficult  operation. 

Simple  Salpingectomy. — Trendelenburg's  position  is  essential  to  com- 
fortable work  in  the  pelvis.  The  Fallopian  tube  must  not  be  rough]}' 
isolated  and  removed,  as  is  frequently  done  by  inexperienced  surgeons. 
After  carefully  packing  back  the  intestines  seize  the  fundus  of  the  uterus 
with  vulsellum  forceps  and  bring  it  up  into  the  wound,  which  should  be 
large  enough  to  admit  of  comfortable  manipulations.  Separate  light 
adhesions  by  gauze  sponging,  taking  pains  not  to  damage  intestines  or 
to  rupture  a  distended  tube.     Tie  off  with  catgut  the  infundibulopelvic 


Fig.  205. — Incision  for  removal  of  diseased  tube  from  uterus. 

ligament  between  the  ovary  and  the  wall  of  the  pelvis.  Then  ligate  a 
small  section  of  the  broad  ligament  where  it  joins  the  uterus,  close 
below,  but  not  including  the  tube.  These  two  ligatures  control  the  blood- 
supply.  Next  seize  the  tube  and  ovary  and  excise  them  with  scissors. 
Excise  the  whole  tube,  dissecting  it  out  from  the  fundus  of  the  vtenis,  and 
close  the  uterine  wovmd  with  catgut  stitches.  Do  not  tie  off  the  tube  and 
leave  a  stump. ^     Such  a  stump  may  be  a  focus  for  future  trouble.     We 

'The  surgeon  should  have  in  mind  possible  future  pregnancies.  In  this  con- 
nection M.  Storer  writes  in  a  personal  communication:  "  I  often  cut  the  tube  off  an 
inch  from  the  uterus  and  stitch  the  peritoneum  to  the  endothelium,  in  those  cases 
in  which  a  subsequent  pregnancy  is  de.'^ired.  Sometimes  these  patients  conceive 
later.  If  the  tube  is  thickened  all  the  way,  I  excise  a  wedge-shaped  piece  out  of 
the  fundus  of  the  uterus;  but  if  the  uterine  end  be  apparently  normal,  I  hesitate 
about  making  it  impossible  for  the  patient  to  have  another  child — and  I  have  had 
very  few  secondary  operatiojis." 


SALPINGITIS  "^27 


now  have  to  close  the  rent  in  the  broad  ligament.  I  usually  sew  it  up 
with  a  buttonhole  catgut  stitch.  Dudley  sews  it  up  by  a  shortennig 
method  first  converting  the  rent  into  a  V-shape  and  approximatmg 
the  distal  to  the  proximal  end.  Either  method  is  good,  but  Dudley's 
method  doubtless  furnishes  the  better  support  to  the  uterus. 

If  the  tube  and  ovary  have  been  removed  in  this  manner  without 
encountering  complications  and  without  soiling  the  peritoneum,  the 
abdomen  may  then  be  closed,  and  a  perfect  convalescence  expected. 

Complications.— A  discussion  of  the  varying  comphcations  and 
difficult  situations  which  may  arise  in  clearing  up  a  pelvis  thoroughly 
infected  and  containing  matted  masses  of,  viscera  would  involve  us  m 
many  words.     I  shall  i7idicate  merely  procedures  to  be  followed,  while 
the  reader  must  bear  in  mind  the  intricate  conditions  I  have  already 
described.     The  presence  or  absence  of  pus  is  the  leading  question  to  be 
considered;  next,  the  extent  and  intricacy  of  adhesions.     Moreover, 
the  pus  may  be  sterile  or  infectious,  and  adhesions  may  be  shght,  or 
they  may  implicate  the   entire  thickness  of  a  viscus.     If  extensive 
parametric  abscess  be  associated  with  pyosalpinx,  whether  or  not  the 
two  communicate,  it  is  best  first  to  drain  the  abscess  from  below,  as  1 
stated  when  treating  of  vaginal  section,  though  many  competent  sur- 
geons advise  and  practise  completing  the  operation  and  removing  the 
tube  through  the  vagina.     Without  entering  into  this  controversy  1 
must  record  my  objection  to  the  vaginal  operation.     It  is  impossible 
by  the  vaginal  route  to  deal  satisfactorily  with  densely  adherent  or 
possibly  torn  intestines  or  with  a  diseased  appendix. 
^     With  the  patient  in  the  Trendelenburg  position,  and  with  the  viscera 
carefully  walled  off  so  far  as  possible,  one  proceeds  to  the  abdominal 
operatio"^   by   gently    and   patiently   disentangling   the  masses      One 
searches  for' the  points  of  least  resistance,  ^^'^^^^^^fl^^^ll  '"^^l 
yielding  sulci,  wipes  out  fluid,  separates  and  packs  off  f^'^^-^^^'^^^^^ 
repairs  intestinal,  bladder,  or  ureteral  rents  if  they  occur      Thus  grad 
ually  the  mass  is  broken  up  and  the  individual  «^-g?;j^^^7f  ,^^^^^^^^^^ 
When  this  is  accomphshed,  there  usually  r em ams  still  an  mteresting 
problem  to  solve.     Shall  the  uterus  be  removed  with  the  tubes  or  shal 
it  be  left?     The  answer  to  this  question  depends  upon  the  extent  ot 
the  metritis.     This  is  a  point  which  we  considered  m  the  las.  chapte 
but  in  general  terms  be  it  said  that  it  is  safer  to  remove  a  highly  inflamed 
uterus  than  to  leave  it  as  a  source  of  continued  ^^^^^^^^^^^  T^V^Hhe 
ing  of  the  French  school  is  that  uteri  should  always  be  removed  ^  hen  the 
acfnexa  are  removed.     I  do  not  subscribe  to  this  view.  J^^^^l^J^^^ 
finds  a  case  so  difficult  that  completion  of  the  operation   ^^^^^P^^^^^^^^^ 
on  account  of  the  imminent  danger  to  hfe,  through  spi;ead  «    "  ectmn 
and  destruction  of  intestines.     In  such  a  case  it  is  well  to^^^"^  ^  ^^^J 
gauze  the  pelvis  both  from  above  and  from  below.     After  some  days  o 
leeks  of  such  drainage  it  may  be  possible  to  complete  the  operation  at 
a  second  sitting.     Hemorrhage  is  another  complication  which  mvist  caie 
fully  be  guarded  against.     Extensive  oozmg  is  ;°™«^^ ,  ^^^^^^^^'^^^ 
vessels  are  often  so  obscure  that  they  cannot  be  found.     Secondary 


328 


FEMALE  ORGAN'S  OF  GENERATIOX 


hemorrhage  is  not  infrequent.  I  have  had  three  shocking  cases  of  death 
from  secondary  hemorrhage  follow  this  operation.  lor  these  reasons, 
as  well  as  on  account  of  the  septic  condition  of  the  deep  field,  abdominal 
drainage  is  essential  after  all  operations  for  complicated  pelvic  inflam- 


Fig.  203.— Diagram  of  the  condition  after  removal  of  the  right  tube  and  left  ovarj', 
showing  the  distance  separating  the  remaining  tube  and  ovary  (Kelly). 

mations.  I  use  and  am  satisfied  with  a  cigaret  drain  passed  through  a 
stab-wound  above  the  pubes  and  carried  to  the  bottom  of  the  pelvis. 
The  abdominal  wound  is  then  closed  tightly.     By  using  this  stab-wound 


Fig.  207. — Diseased  tube:  area  of  obliteration  excised. 


one  renders  the  abdominal  wall  strong  and  tight,  little  liable  to  hernia 
in  the  scar.  In  case  of  tuberculosis  of  the  tubes  they  should  be  removed 
and  the  pelvis  drained.  When  the  uterus  as  well  as  the  tubes  is  con- 
cerned in  the  tuberculous  process,  total  hysterectomy  should  be  per- 


TUMORS   OF   THE    FALLOPIAN   TUBER  329 

formed,  unless  extensive  tuberculous  involvement  of  other  abdominal 
organs  renders  hysterectomy  obviously  futile. 

Conservative  operations  on  the  tubes  and  ovaries  have  been  advocated 
for  the  past  twenty  years.  Schroder  and  Martin,  as  well  as  the  Amer- 
ican Polk,  were  advocates  of  such  operations;  while  Dudley,  Kelly, 
Morris,  Storer,  and  Reynolds  have  made  valuable  contributions  to 
the  literature  of  this  subject.  In  brief,  these  operations  aim  at  pre- 
serving some  small  but  sound  portion  of  diseased  ovaries,  and  at  re- 
establishing the  lumen  of  twisted  and  obstructed  tubes.  I  shall  have  a 
word  to  say  shortly  in  regard  to  the  conservative  treatment  of  ovaries; 
as  for  tubes,  there  is  abundant  evidence  that  in  certain  cases  when 
damaged  they  may  be  restored  to  function,  for  after  such  operations 
conception  and  pregnancy  have  occurred — results  impossible  under  the 
conditions  founcl  to  exist  before  the  operation.  The  obliterated  end  of 
a  tube  may  be  resected  or  rendered  patent,  and  attached  to  a  func- 


Fig.  208. — Conservative  resection  of  tube,  operation  complete. 

tionating  ovary.  Obliterating  cicatrices  are  excised  from  the  ampulla, 
and  end-to-end  suture  performed,  restoring  the  tube's  lumen;  while  an 
ingenious  operation,  similar  to  that  of  the  Heineke-Mikulicz  pyloroplasty, 
will  overcome  tubal  stenosis, 

TUMORS  OF  THE  FALLOPIAN  TUBES 

There  are  tumors  of  the  Fallopian  tubes — infrequent ,  little  regarded. 
Inasmuch  as  the  tubes  contain  the  same  histologic  elements  as  the  uterus, 
they  may  be  the  seat  of  tumors  similar  to  uterine  tumors.  It  is  ex- 
tremely difficult  or  impossible  to  distinguish  clinically  these  growths 
from  tumors  of  the  ovary.  Generally,  the  diagnosis  is  made  on  the 
operating  table. 

There  are  tubal  papillomata  springing  from  the  adenomatous  tissue 
of  the  mucous  glands.  Such  growths  are  a  menace  to  life  because  they 
are  liable  to  invade  the  peritoneal  cavity,  there  to  spread  rapidly  and 


330  FEMALE  ORGANS  OF  GEXERATION 

involve  other  organs.  The  possible  presence  of  such  a  tumor  is  always 
to  be  considered  when  one  is  dealing  with  pelvic  neoplasms.  This  is  a 
strong  reason  for  removing  all  pelvic  growths.  If  possible,  a  Fallopian 
papilloma  should  be  excised  promptly  and  entire.  If  it  has  invaded  the 
peritoneum,  its  removal  generally  is  impossible.  One  finds  the  abdom- 
inal cavity  filled  sometimes  with  these  papillomatous  growths  from 
the  tubes — -growths  easily  bleeding  and  giving  rise  to  a  considerable 
accumulation  of  ascites-like,  bloody  fluid.  Such  growths,  if  unchecked, 
prove  fatal  rapidly. 

There  are  cystomata  of  the  Fallopian  tubes — retention  cysts  of  the 
mucous  follicles  found  generally  in  the  vestibule. 

There  are  rare  myomata. 

There  are  carcinomata  and  sarcomata  of  the  tubes — infrequent 
diseases,  primary  in  the  tubes  almost  never.  A'eedless  to  say,  they 
should  be  removed  early,  if  at  all. 

THE  BROAD   LIGAMENTS 

The  broad  ligaments  may  be  the  site  of  solid  tumors  and  cysts  less 
frequently  than  of  inflammations.  Rarely  malignant  disease  may 
develop  there,  but  benign  disease  is  not  uncommon.  You  will  find 
cysts,  mvomata,  lipomata,  dermoids,  cancer,  sarcoma. 

Cysts  are  the  interesting  broad-ligament  growths.  They  are  dif- 
ficult to  distinguish  clinically  from  ovarian  cysts.  The  terms  'par- 
ovarian and  intraligamentous  cysts  are  applied  to  them.  In  almost  all 
cases  they  are  developed  out  of  the  remnants  of  the  Wolffian  duct,  which 
lies  in  the  broad  ligament  below  the  Fallopian  tube.  These  cysts  are 
commonly  unilocular  and  contain  a  thin,  straw-colored  fluid.  If  they 
have  not  become  inflamed,  they  niay  be  peeled  out  from  the  broad 
ligament. 

The  symptoms  of  parovarian  cysts  are  in  direct  relation  to  the 
size  of  the  C3\st  and  the  pressure  it  exerts  on  neighboring  organs.  Pres- 
sure may  cause  general  pelvic  discomfort,  varying  pains,  dysmenorrhea, 
and  irritation  of  the  bladder  and  rectum.  The  treatment  consists 
in  enucleating  the  sac,  and  this  generally  can  be  accomplished.  Some- 
times, when  there  are  extremely  complicating  adhesions,  one  may  be 
obliged  to  pack  the  cavity  after  the  cyst's  removal  and  allow  healing 
by  granulation.  In  the  rare  cases  of  pedunculated  parovarian  cysts 
the  surgeon  usually  ties  off  the  growth.  Rarely  supravaginal  hyster- 
ectomy must  be  our  resource  in  dealing  with  intraligamentous  cysts. 
In  operating  avoid  injuring  the  ureters. 

Hydrocele  of  the  round  ligaments  is  a  condition  analogous  to 
hydrocele  of  the  spermatic  cord.  The  accumulated  fluid  is  in  the  canal 
of  Nuck,  and  appears  as  a  fluctuating  tumor  at  the  internal  ring,  or 
even  lower,  in  the  mens  or  the  tip  of  the  labium.  This  condition  cannot 
always  be  differentiated  from  inguinal  hernia.  The  treatment  consists  in 
laying  open  and  removing  the  hydrocele  sac. 

Solid  tumors  of  the  broad  ligament  usually  lie  between  the  peritoneal 


THE   OVARIES  331 

folds,  though  rarely  they  may  become  pedunculated.  They  may 
grow  to  any  size,  if  non-malignant,  though  nowadays  they  are  usually 
discovered  and  removed  when  small.  It  is  almost  impossible  to  dis- 
tinguish them  from  ovarian  or  uterine  tumors  before  the  abdomen  is 
opened.  The  only  treatment  is  operative.  Open  the  abdomen  either 
from  above  or  through  the  vagina.  Certain  writers  direct  that  the 
vaginal  route  invariably  be  chosen.  Such  advice  is  not  consistent  with 
good  surgery.  \Micn  difficult  and  complicating  conditions  exist  in 
these  cases,  as  in  other  forms  of  pelvic  disease,  it  may  be  necessary  to 
clean  out  the  pelvis  by  removing  the  uteiiis  and  its  adnexa. 

Dermoid  cysts  have  been  found  occupying  the  broad  ligament. 
Their  syinptotns  and  treatment  are  quite  similar  to  those  of  solid  tumors. 

Solid  tumors  of  the  round  ligament  ^  are  rare.  They  may  develop 
in  the  canal  or  within  the  abdomen.  Except  when  large,  they  cause  no 
special  symptoms,  but  they  should  be  removed  when  discovered. 

Varicocele  of  the  broad  ligament  is  not  infrequent;  indeed,  dilated 
veins  are  often  found  in  various  parts  of  the  pelvis,  associated  with 
tumors  and  pregnancy.  The  common  varicocele  of  the  broad  ligament 
is  a  dilatation  of  the  veins  of  the  ovarian  pampiniform  plexus.  This 
varicocele  generally  is  caused  by  an  arrest  of  involution  of  the  vessels 
following  labor,  by  inflammation  of  the  veins,  or  by  the  existence  of 
long  ovarian  veins  unable  to  propel  the  great  weight  of  blood.  Con- 
stipation and  uterine  displacements  are  other  causes.  The  left  ovarian 
vein  frequently  enters  the  left  renal  vein  and  may  be  obstructed  by  an 
overlying,  heavy  sigmoid  flexure,  loaded  with  feces.  Such  are  some  of 
the  causes  of  these  varices,  though  the  etiology  is  not  always  clear. 
The  patient  suffers  from  dull,  aching  pain  in  the  pelvis  when  she  stands. 
Menstruation  is  wont  to  be  frequent.  The  diagnosis  may  be  obscure, 
though  rarely,  in  thin  subjects,  one  may  palpate  the  varicocele.  The 
only  satisfactory  treatment  is  abdominal  section  and  excision  of  the  veins. 

Malignant  disease  of  the  broad  ligament  is  uncommon,  and  when 
present,  is  usually  secondar}^  to  disease  of  the  uterus  and  other  organs. 
Extirpation  of  such  disease  of  the  ligaments  seldom  is  possible. 

The  Ovaries 

The  ovaries  are  organs  of  such  vital  interest  to  patient  and  surgeons 
that  ihey  deserve  more  than  the  short  notice  I  can  give  them  in  this 
chapter.  They  are  interesting  physiologically  as  well  as  pathologic- 
ally. Their  disease  or  removal  means  more  than  sterility  to  a  woman, 
but  we  must  limit  ourselves  to  a  brief  consideration  of  their  surgical 
diseases. 

OVARITIS 

Ovaritis  as  a  complication  of  salpingitis  is  common,  but  the  surgeon 
must  be  careful  to  distinguish  true  ovarian  inflammation  from  ovarian 
hj-peremia.     The  latter  condition  may  be  caused  by  malpositions,  by 

1  Barton  Cooke  Hirst  and  Norman  Knipe  report^  an  extremely  interesting  case 
of  this  nature  in  Surg.,  Gyn.,  and  Obstet.,  1907,  vol.  iv,  p.  715. 


332  FEMALE  ORGAXS  OF  GENERATION 

twists  of  the  ovarian  pedicle,  and  by  sundry  traumatic  irritations. 
Acute  ovantis  is  almost  always  due  to  the  streptococcus.  The  gono- 
coccus  is  more  apt  to  give  rise  to  a  periovaritis.  Tuberculous  ovaritis 
is  not  especially  uncommon.  It  arises  from  infection  transmitted 
through  the  Fallopian  tube,  through  a  tuberculous  vaginal  lesion, 
through  the  peritoneum,  or  rarely  through  the  general  circulation. 

It  is  not  always  possible  to  make  a  positive  differential  diagnosis 
of  the  above-named  forms  of  ovaritis.  All  of  them  are  characterized 
by  general  or  localized  pelvic  pain,  by  dysmenorrhea,  by  local  tender- 
ness, by  enlargement  of  the  ovary,  by  its  displacement,  b}-  adhesions, 
and  sometimes  by  evidences  of  a  general  infection.  Frequently  the 
tubes,  the  uterus,  and  the  peritoneum  are  involved  in  the  process. 

One  must  distinguish  also  l>etween  acute  and  chronic  ovaritis.  In 
typical  cases  acute  ovaritis  is  characterized  by  an  enlarged,  tense,  elastic 
ovary,  with  or  without  adhesions,  together  with  the  associated  condi- 
tions I  have  mentioned;  while  chronic  ovaritis  is  usually  an  outcome 
of  acute  ovaritis.  In  chronic  ovaritis  the  ovarj-  is  at  first  swollen  and 
hard;  later,  nodular  and  cystic,  with  symptoms  of  a  less  intense  charac- 
ter, such  as  I  described  when  speaking  of  chronic  salpingitis.  In 
general  terms  inflammations  of  the  ovary  are  so  closety  associated  with 
inflammations  of  the  tube  that  we  must  consider  both  organs  when  we 
come  to  the  subject  of  treatment. 

Treatment. — If  the  attack  is  acute,  general  symptomatic  treatment 
should  be  followed:  absolute  rest,  the  giving  of  saline  laxatives,  and 
hot  vaginal  douches  and  glycerin  tampons  on  alternate  days,  with  an 
ice-bag  over  the  groin.  Such  treatment  is  indicated  especially  in  the 
case  of  gonorrheal  infection.  When  the  inflammation  is  due  to  the 
streptococcus,  the  symptoms  are  wont  to  be  more  severe,  and  pus-for- 
mation is  more  certain,  so  that  vaginal  drainage  may  be  our  resort. 

In  the  case  of  chronic  ovaritis  palliative  measures,  such  as  I  des- 
cribed in  the  last  paragraph,  may  suffice  for  a  time;  but  for  permanent 
cure  we  must  resort  usually  to  an  operation.  This  subject  of  what 
operation  to  perform  on  chronically  inflamed  ovaries  is  intricate  and 
difficult,  because  the  operation  depends  largely  for  its  success  on  the 
condition  of  the  tubes.  For  the  lazy  surgeon  it  is  easy  to  answer  the 
question  by  removing  both  tubes  and  ovaries.  Often,  however,  such 
radical  procedures  are  needlessly  crippling,  and  conservative  treatment 
may  be  followed  by  a  brilliant,  satisfactory  result.  In  any  case  a 
portion  at  least  of  one  ovary  should  be  preserved  in  order  to  obviate  an 
artificial  menopause,  and  to  forestall  the  so-called  reflex  neuroses  which 
so  commonly  afflict  young  women  deprived  suddenly  of  both  ovaries. 
After  the  menopause  the  ovaries  may  be  removed  with  more  freedom. 
Conservative  operations  on  the  ovaries  consist  in  the  puncture  and 
cauterization  of  cysts,  the  excision  of  scar  tissue,  and  the  stitching  of 
the  ovary  into  proper  relations  with  the  open  tube.  If  the  tube  itself 
is  diseased,  one  may  treat  it  by  some  such  plastic  operation  as  I  have 
described  in  a  previous  paragraph. 

If  the  ovary  is  tuberculous,  it  should  be  removed,  together  with 


TUMORS   OF   THE   OVAltlES 


333 


the  corresponding  tube,  and  the  operation  should  include  complete 
extirpation  of  the  tubal  isthmus,  with  suture  of  the  resulting  wound 
in  the  uterus.     If  the  ovary  alone  is  removed,  the  pedicle  should  be 


Fig.  209. — Repair  of  broad  ligament  after  removal  of  ovary — step  1. 

carefully  secured  by  suture  and  the  rent  in  the  broad  ligament  repaired, 
after  the  fashion  I  described  when  speaking  of  removal  of  the  tubes. 

TUMORS  OF  THE  OVARIES 

Twenty-five  years  ago  ovariotomy  was  the  magnum  opus  of  ab- 
dominal surgeons,  and  to-day  even  the  operation  creates  a  surprising 
amount  of  interest,  for  ovarian  tumors  generally  can  be  removed  entire. 


Fig.  210. — Repair  of  broad  ligament — step  2. 

and  their  removal  releases  the  patient  from  painful,  distressing  invalid- 
ism, and  retuiTLS  her  with  promptness  and  completeness  to  vigorous, 
normal  health. 


334 


FEMALE  ORGANS  OF  OENEUATION 


As  with  tumors  elsewhere,   ovarian  tumors  are  of  ^reat  variety, 
though  ovarian  cysts  are  the  tumors  most  famihar  and  most  satisfac- 


Fig.  211. — Repair  of  l)road  ligament — step  3. 

tory  in  treatment.     Ovarian  tumors  are  l^enign  or  malignant.     Primary 
cancer  is  the  commonest  form  of  malignant  ovarian  disease. 


Fig.  - 12.      I'^normous  nvarian  eyst.     A\'('iglit,    12N    pounds    (Massachusetts    (Jcucral 

H()s])itan. 

There  are  sundry  forms  of  ovarian  cysts:  Follicular  cysts  are  pri- 
marily  dilated   follicles,    the   result   of  previous   inflammalion.     They 


TUMORS    OF   THE    OVARIES 


33^ 


develop  on  the  surface  of  the  ovary,  are  of  slow  growth,  and  vary  from 
the  size  of  a  bean  to  that  of  an  adult  head.  These  cysts  may  be  single 
or  multiple;  gradually  they  destroy  the  ovarian  tissue  and  appear  as 
large  water-bags  containing  straw-colored  fluid  or  fluid  turbid  with 
changed  blood.  Cysts  of  the  corpus  luleuni  develop  in  a  ruptured 
follicle.  They  grow  slowly,  and  do  not  become  so  large  as  the  follicu- 
lar cysts;  again,  unlike  the  follicular  cysts,  they  are  usually  single. 
They  contain  clear,  serous  fluid.  Tnbo-ovarian  cysts  develop  in  ovaries 
and  tubes  at  once,  but  they  are  priniar}'  in  the  ovary;  they  are  of  fol- 
licular origin,  and  involve  the  tubes  through  inflamed  adhesions.    Rarely 


Fig.  213. — Papillomata  of  both  ovaries  seen  from  behind  (Kelly).  On  the  left  side 
a  series  of  mulberry  masses  are  seen  hangino;  from  a  delicate  pedicle  attached  to  the 
Fallopian  tube;  on  the  right,  the  ovary  is  transformed  into  a  mulberry-  mass,  and 
inside  a  cyst  two  masses  are  seen  sprouting. 


do  they  exceed  an  orange  in  size.  They  contain  a  clear  fluid  also,  and 
are  unique  in  this  respect,  that  they  may  communicate  with  the  cavity 
of  the  uterus,  through  which  exit  occasionally  their  contents  maj^  escape. 
Proliferating  or  neoplastic  cystoniata  are  more  rare.  They  are  not 
retention  cj^sts,  but  are  true  new  formations,  papillarj'  or  glandular, 
according  as  they  contain  papillary  growths  or  not.  Their  contents 
may  resemble  mucin  (pseudomucin)  or  may  be  serous.  The  papillary 
cysts  may  grow  to  a  great  size,  and  are  most  common  in  women  who 
are  unmarried  or  sterile.  Such  cysts  generally  are  single,  though  they 
may  be  multiple.  The  fluid,  when  drawn  off,  is  found  to  be  of  a  thick, 
rop3^  consistency.     The  serous  cysts  are  less  common  than  the  papillary 


336  FEMALE  OKGAXS  OF  GENERATION 

proliferating  cysts,  nor  do  they  grow  so  large.  These  serous  cysts 
often  develop  within  the  folds  of  the  broad  ligament,  and  are  wont  to 
form  adhesions  with  neighboring  organs. 

We  must  note  especially  the  proliferating  cysts.  Though  histo- 
logically benign,  they  develop  rapidly,  and  in  their  removal  portions 
may  become  detached  and  implanted  elsewhere  in  the  peritoneal  cav- 
ity. There  they  grow  and  nmltiply,  forming  metastases.  Sometimes 
malignant  degeneration  occurs,  when  either  carcinoma  or  sarcoma 
may  develop.  So  these  proliferating  cysts  are  to  be  dreaded.  If 
you  open  the  abdomen  to  remove  an  ovarian  tumor,  and  find  in  the 
peritoneal  cavity  free  fluid,  bloody  and  serous,  look  for  a  proliferating 
cyst ;  remove  it  entire,  if  possible,  but  give  a  guarded  prognosis. 

Dermoid  cysts  are  the  least  common  of  ovarian  cysts.  Usually,  they 
are  pedunculated,  though  sometimes  they  may  develop  within  the  folds 
of  the  broad  ligament.  They  grow  slowly  and  rarely  exceed  in  size  an 
adult  head.  Commonly  they  are  single,  and  contain  various  substances: 
fat-like  material,  hair,  teeth,  and  bones.  The  probability  is  that  these 
growths  have  their  origin  in  the  ovule,  which  possesses  the  elements 
needed  for  the  development  of  human  tissues  and  structures. 

Solid  tumors  of  the  ovary  are  rare  also.  They  are  usually  rounded, 
smooth,  and  pedunculated,  though  they  too  may  lie  in  the  broad  lig- 
ament. Often  they  are  associated  with  cysts.  Of  these  tumors,  fibro- 
mata are  the  mo.st  common.  Myomata  are  rare.  Within  the  fibro- 
mata myxomatous  changes  may  occur  and  calcareous  matter  may  be 
deposited. 

We  find  primary  cancer  of  the  ovary,  medullar\^  carcinoma,  and 
adenocarcinoma.  Medullary  carcinomata,  like  other  solid  ovarian 
tumors,  are  both  pedunculated  and  intraligamentous.  The  adeno- 
carcinomata  are  made  up  of  cystic  tumors,  usually  pedunculated,  at- 
taining the  size  of  a  child's  head,  frequently  adherent  to  other  organs, 
with  papillary  excrescences.  It  is  not  always  easy  at  once  to  distin- 
guish the  adenocarcinomata  from  non-malignant  proliferating  cysts. 
Secondary  malignant  growths  in  the  ovaries  often  result  from  uterine 
neoplasms.  There  are  also  ovarian  ejidotheliomata,  springing  from  the 
blood-  and  lymph-vessels  of  the  ovar\'.  Like  other  malignant  diseases 
they  occur  in  middle  life,  but  may  develop  in  childhood. 

Hematoma  of  the  ovary  must  be  mentioned — a  distinct  tumor  reach- 
ing the  size  of  a  small  orange.     It  is  rarely  made  out  before  operation. 

The  symptoms  of  an  ovarian  tumor  vary  with  the  nature  of  the 
growth  and  with  its  size  and  attachments.  Most  benign  tumors  cause 
trouble  from  their  size  and  pressure  only,  though  frequently,  in  the  case 
of  small  ovarian  cysts,  the  patient  is  aware  of  some  pelvic  discomfort, 
and  may  complain  of  exaggerated  menstrual  pain.  An  exception  to 
this  lack  of  frequent  pain  is  the  case  of  an  ovarian  tumor  with  a  tuisted 
pedicle.  There  is  a  great  literature  on  this  subject.  Small  ovarian 
tumors,  as  well  as  large  ones,  may  become  twisted,  the  twist  being 
usually  from  left  to  right,  or  as  the  hands  of  a  watch  move.  The  ped- 
icle may  twist  through  many  degrees,  depending  upon  its  length  and 


TUMORS    OF    THE    OVARIES  337 

mobility.  Twists  of  four  or  even  five  complete  turns  have  been  re- 
ported, though  usually  one  complete  revolution  is  enough  to  set  up  acute 
symj)tonis  and  send  the  patient  to  a  surgeon.  These  twists  cause  stran- 
gulation of  the  vessels,  engorgement  of  the  tumor,  and  agonizing  pain, 
which  may  be  spontaneously  relieved  after  a  time  by  a  partial  untwist- 
ing. The  twist  may  occur  independently  of  menstruation.  The  great 
danger  of  the  condition  lies  in  the  probability  of  a  firm  permanent  twist 
resulting  in  gangrene  of  the  tumor. ^  Another  form  of  non-malignant 
tumor  which  gives  rise  to  pain  is  the  dermoid  cyst.  Ovarian  cysts  may 
rupture  and  apparently  disappear.  As  a  general  thing,  however, 
ovarian  cysts  reach  a  considerable  size  before  causing  pronounced 
symptoms;  these  symptoms  may  be  amenorrhea  or  other  menstrual 
disturbances,  but  the  pronounced  symptoms  are  due  to  mechanical 
pressure.  One  hears  of  bladder,  rectal,  and  renal  disturbances,  with 
great  swellings  of  the  abdomen,  of  edema  of  the  legs,  of  hemorrhoids, 
and  sometimes  of  ascites.  In  the  case  of  solid  benign  tumors  the 
symptoms  vary  little  from  those  which  I  have  just  described,  but  malig- 
nant tumors  cause  pain,  cachexia,  wasting,  and  the  other  conditions 
common  to  all  late  malignant  disease. 

The  diagnosis  of  ovarian  ttunor  may  be  easy,  or  it  may  be  extremely 
difficult.  The  history  and  symptoms  count  for  little,  as  tumors  of 
other  organs,  especially  of  the  uterus  and  tubes,  give  rise  to  similar 
symptoms.  We  must  depend  on  our  physical  examination.  A  typical 
ovarian  cyst  may  be  handled  bimanually.  It  feels  like  a  rounded, 
smooth,  elastic,  movable  mass,  occupying  the  pelvis  or  lower  portion  of 
the  abdomen.  Nowadays  these  tumors  rarely  reach  the  great  size 
shown  in  the  old  text-books  as  classic.  Surgeons  discover  ovarian 
cysts  early  in  their  growth,  and  take  them  out  long  before  the  tumor 
fills  the  abdominal  cavity.  If  the  cyst  is  large,  it  may  be  confounded 
W'ith  ascites  or  other  causes  of  abdominal  distention.  Note,  however, 
that  free  fluid  in  the  abdomen  settles  in  the  flanks  and  gives  rise  to 
shifting  dulness  when  the  patient  turns.  On  the  other  hand,  a  great 
ovarian  cyst  is  shown  by  central  dulness  which  does  not  shift.  But  the 
small  tumors  usually  found  are  mapped  out  as  small  tumors.  Some- 
times they  are  so  soft  and  flabby  as  not  to  be  felt.  Sometimes  they  are 
so  hard  and  tense  as  to  be  mistaken  for  solid  tumors.  Every  surgeon 
has  cut  down  upon  an  ovarian  cyst  under  the  mistaken  impression  that 
it  was  a  myoma  of  the  uterus.  Extensive  adhesions  and  concurrent 
new-growths  complicate  further  the  diagnosis.  Solid  ovarian  tumors 
also  may  be  distinguished  as  discrete,  movable  masses,  or  they  may  be 
mistaken  for  tumors  of  the  uterus,  tubes,  or  broad  ligaments.  Preg- 
nancy may  complicate  and  confuse  the  diagnosis.  Rapidly  grow-ing 
tumors,  rather  than  tumors  of  slow  growth,  are  likely  to  be  malignant. 
Sudden  increase  in  size,  associated  wath  acute  pain,  is  usually  due  to 
torsion  of  the  ovarian  pedicle.  Pregnancy  may  be  distingiiished  by 
the  patient's  vomiting,  by  enlargement  of  her  breasts,  softening  of  the 
cervix,  placental  bruit,  and  perhaps  by  fetal  heart-sounds.     Uterine 

1  See  article  by  M.  Storer,  Boston  Med.  and  Surg.  Jour.,  November  5,  1896. 
22 


338  FEMALE  ORGANS  OF  GENERATION 

tumors  are  usually  distinguished,  among  other  signs,  by  elongation  of 
the  uterine  canal,  as  shown  by  the  exi)loring  probe. 

In  spite  of  all  tests,  with  which  the  literature  of  this  subject  abounds, 
the  most  experienced  surgeon  may  make  mistakes.  In  this  case,  es- 
pecially if  synijitoms  persist  and  become  aggravated,  one  nmst  resort  to 
an  exploratory  operation. 

The  prognosis  of  ovarian  tumors  untreated  is  illustrated  by  the 
abundant  and  curious  literature  of  the  last  century,  and  the  prog- 
nosis varies  as  greatly  as  do  the  gi'owths  of  which  that  literature  treats. 
In  general  terms,  benign  tumors  produce  slowly  developing  invalidism, 
sterility,  neuroses,  exhaustion,  impairment  of  the  functions  of  the 
abdominal  organs,  wasting,  and  a  lingering  death  after  many  }'ears. 
Malignant  disease  of  the  ovaries  advances  rapidly  in  the  familiar  fash- 
ion, with  metastases,  extensive  involvement,  cachexia,  and  death  in 
from  one  to  two  years.  Furthermore,  one  may  never  say  when  the 
benign  may  become  the  malign,  so  that  in  every  case  extirpation  of 
the  growth  is  the  surgeon's  duty. 

Ovariotomy. — The  subject  of  removal  of  ovarian  tumors  marks  one 
of  the  proudest  chapters  in  American  surgery.  Ephraim  McDowell, 
of  Danville,  Kentucky,  in  1809,  was  the  first  surgeon  to  remove  an 
ovarian  tumor.  Nathan  Smith,  of  Dartmouth  and  Yale,  in  1S21, 
removed  an  ovarian  tumor  without  knowledge  of  McDowell's  work. 
Slowly  the  practice  extended  so  that  now,  for  a  hundred  years,  ovarian 
surgery  has  been  recognized  and  followed  in  this  country.  It  was  not 
until  the  development  of  aseptic  surgery,  however,  that  the  practice 
became  universally  established.  Ovariotomy  is  a  misnomer.  Prop- 
erly, the  term  should  be  oophorectomy,*  but  that  word  is  commonly 
used  to  designate  the  removal  of  an  inflamed  ovary,  while  ovariotomy, 
meaning  properly  the  cutting  open  of  an  ovary,  has  come  to  designate 
the  removal  of  an  ovarian  tumor. 

No  form  of  treatment  other  than  extirpation  serves  to  remove 
ovarian  tumors.  Let  me  say  a  preliminary  word  in  regard  to  the  re- 
moval of  solid  tumors  of  the  ovary.  The  technic  is  extremely  simple; 
the  maneuver  differs  in  no  essential  respect  from  that  of  the  removal 
of  a  tumor  of  the  tube. 

The  surgeon  opens  the  abdomen  near  the  median  line  by  a  longitudi- 
nal incision;  walls  back  the  intestines,  with  the  patient  in  the  Trendelen- 
burg position;  seeks  the  tumor;  clamps  its  pedicle,  or  dissects  out  the 
mass  if  it  be  intraligamentous ;  removes  the  growth,  and  repairs  the  rent 
in  the  broad  ligament.  All  this  is  simple.  So  accomplished  a  surgeon 
as  M.  H.  Richardson  maintains  that  all  ovarian  tumors,  cysts  as  well 
as  solid  tumors,  should  be  removed  entire  in  this  fashion,  for  one  cannot 
always  foresee  the  nature  of  a  cyst  before  it  is  opened.  It  may  contain 
malignant  elements,  in  which  case  its  removal  uniuptured  and  entire 
will  forestall  subsequent  malignant  involvement  of  other  parts.  I 
S3'mpathize  entirely  with  this  view,  and  recommend  the  total  removal 
of  ovarian  tumors  unruptured  in  most  cases.      Occasionalh',  however, 

1  Greek,  ii>6v,  (ptjxj. 


TUMORS   OF  THE    OVARIES  339 

one  (encounters  an  ovarian  tumor  so  enormous  or  so  extensively  ad- 
herent that  its  removal  by  a  motlification  of  the  classic  tapping 
method  is  inevitable.  That  classic  method  is  still  useful.  As  ovari- 
otomy was  the  operation  of  pioneers  in  abdominal  surgery,  the  subject 
was  long  involved  in  a  voluminous  and  needless  discussion  relating  to 
details  of  technic,  and  countless  curious  instruments  and  other  matters 
with  which  early  Listerism  concerned  itself.  To-day  the  classic  opera- 
tion even  is  simple  enough,  and,  as  John  Homans  used  to  say,  its  only 
point  of  interest  for  the  surgeon  lies  in  his  endeavor  to  operate  through 
the  smallest  possible  abdominal  opening. 

One  enters  the  abdomen  above  the  pubes  through  the  rectus  muscle, 
and  at  once  explores  the  wall  of  the  cyst,  to  ascertain  the  presence  of 
adhesions.  If  the  cyst  is  fairly  free,  the  patient  is  turned  on  the  right 
side,  a  gauze  handkerchief  is  laid  in  to  protect  the  peritoneum  from  dis- 
charges, and  a  Spencer  Wells  trocar  is  plunged  into  the  cyst.  Through 
the  trocar  the  cyst  fluid  is  led  off  by  a  iiibber  tube  into  a  receiving  bucket. 
AYith  the  emptying  of  the  cyst  its  wall  collapses  and  the  surgeon's  as- 
sistant hastens  the  emptying  by  pressing  upon  the  patient's  flanks. 
Should  several  large  cysts  be  present,  they  may  be  tapped  severally, 
the  sac  being  gradually  drawn  out  of  the  wound  by  grasping  forceps 
and  the  tap  incision  being  closed  with  Nelaton's  forceps.  Should  there 
be  no  complications,  the  fluid  contents  may  thus  be  almost  completely 
evacuated,  after  which  the  collapsed  sac  easily  may  be  drawn  outside 
of  the  abdominal  wound.  The  surgeon  then  double-clamps  the  pedicle 
and  dissects  it  between  the  clamps.  We  used  to  apply  the  compUcated 
Staffordshire  knot  to  secure  the  pedicle.  A  better  practice  is  to  ligate 
separately  the  two  divisions  of  the  ovarian  artery  on  either  side  of 
the  pedicle,  then  to  cut  awaj^  the  pedicle  stump  and  repair  the  rent  in 
the  broad  ligament.  By  this  measure  all  danger  of  secondary  hem- 
orrhage is  eliminated,  for  the  student  should  remember,  as  a  point  of 
interest,  that  in  the  old  days  slipping  of  the  hgature  and  fatal  hemor- 
rhage from  the  pedicle  was  an  occasional  accident. 

The  complication  of  adhesions  and  supplementary  growths  must  be 
dealt  with  as  I  have  frequently  before  described — by  dissection  and 
separation  of  adhesions,  by  repair  of  torn  bowel,  and  by  removal  of 
growths. 

Ovarian  tumor  complicating  pregnancy  is  another  serious  con- 
dition which  should  be  recognized  early  by  the  physician  and  promptly 
treated.  The  danger  of  this  complication  lies  in  the  possibility  of 
twisting  of  the  pedicle,  rupture  of  the  cyst,  abortion,  obstruction  to 
labor  necessitating  Cesarean  section,  or  ovariotoni}-  during  labor. 
This  complication,  when  discovered  early,  should  be  met  b}'  early  ovar- 
iotomy. If  the  operation  be  simple,  abortion  is  unlikeh',  especially 
if  liberal  doses  of  codein  or  the  bromids  be  employed  at  once  in  the  after- 
treatment. 


340  FEMALE  ORGANS   OF   GENERATION 


TUBAL   PREGNANCY 


Tubal  pregnancy  is  one  of  the  groat  and  interesting  subjects  of 
niotlern  surgery.  The  clanger  of  the  condition  is  extreme;  the  situation 
is  often  unexpected;  and  prompt,  heroic  treatment  frequently  is  de- 
manded if  life  is  to  be  saved. 

We  were  formerly  wont  to  talk  about  tubal  ]:)regnancy,  ovarian  preg- 
nancy, abdominal  i^regnancy,  but  we  now  know  that  tubal  pregruuicy 
is  properly  the  primar}^  condition  in  all  these  cases,  and  that  apparent 
development  of  the  fetus  in  the  ovary  or  free  in  the  abdomen  is  secondary 
to  primary  tubal  pregnancy.  Extra-uterine  pregnancy  is  a  proper  term, 
as  is  ectopic  gestation. 

The  cause  of  tubal  pregnancy  is  now  generally  recognized  to  be  a 
lodgment  of  the  imjDregnated  ovum  somewhere  in  the  tube.  The  ovum 
does  not  cling  to  the  mucous  lining  of  the  tube,  but  apparently  burrows 
into  it,  lodging  in  some  crypt  or  fold  or  other  abnormal  formation, 
the  consequence  of  a  previous  salpingitis.  The  site  of  lodgment  gener- 
ally is  in  the  ampulla  of  the  tube,  though  isthmic  pregnancy  and  in- 
terstitial pregnancy  (within  the  uterine  wall)  are  not  unknown.  It  is 
needless  here  to  discuss  the  formation  of  the  chorion,  amnion,  decidua, 
and  placenta  further  than  to  state  that  these  structures  develop  on 
lines  similar  to  the  normal,  except  that  the  placenta  is  derived  almost 
entirely  from  the  embryo  and  not  from  the  tubal  mucosa.  As  the 
products  of  conception  develop,  the  wall  of  the  tube  becomes  thinner 
and  thinncn-,  and  in  this  thinning  lies  the  danger  of  the  condition. 

The  course  of  a  tubal  pregnancy  runs  uninterrupted  usually  for  from 
three  to  ten  weeks,  but  during  the  latter  half  of  this  period  one  of  two 
accidents  almost  invariably  occurs — tubal  abortion  or  tubal  rupture. 
Malcolm  Storer  ^  has  shown  that  tubal  abortion  is  a  more  common 
accident  than  at  one  time  was  supposed,  and  occurs  usually  about  the 
sixth  week  of  pregnancy,  while  tubal  rupture  occurs  between  the  eighth 
and  tenth  weeks.  Probably  more  than  half  the  cases  of  tubal  pregnancy 
end  in  tubal  abortion.  This  phenomenon  consists  in  the  expulsion 
of  the  ovum  through  the  open,  fimbriated  end  of  the  tube,  when  it  may 
become  implanted  upon  the  ovary  or  upon  some  other  adjacent  part. 

The  symptoms  of  tubal  abortion  are  pain  of  varying  intensity, 
together  with  an  escape  of  blood  from  the  uterus.  The  pain  is  rather 
characteristic — brief,  stabbing,  not  colicky,  and  by  no  means  so  severe 
as  is  the  pain  of  tubal  rupture.  The  pain  and  the  flowing  lead  the 
patient  to  consult  a  physician.  The  cause  of  the  abortion  is  believed 
to  lie  in  the  fact  that  the  glandless  tubal  mucosa  hypertrophies  but 
slightly,  and  does  not  form  a  decidua,  as  is  found  in  the  uterus.  The 
chorionic  villi  of  the  growing  ovum  perforate  this  thin  layer  and  open 
into  the  enlarged  tubal  vessels,  thus  gi^'ing  rise  to  a  hemorrhage  which 
separates  the  ovum  and  results  in  the  aboi'tion.-  In  most  cases  of  tuljal 
abortion  the  ovum  perishes  with  its  expulsion  from  the  tube,  but  heni- 

1  Boston  Med.  and  Surg.  Jour.,  .January  7,  1904. 

2  Marshall,  Lancet,  March  26,  1!»04. 


TUBAL   PREGNANCY  341 

orrhage  persists  generally  in  both  directions.  Frequently  blood  is 
pounnl  out  into  the  abdoniinnl  cavity  and  within  the  folds  of  the  broad 
ligament.  Pelvic  hematocele,  so  called,  then  results;  the  patient 
may  become  alarmingly  weak,  and  prompt  operative  treatment  be 
imperative.  In  rare  cases  the  ovum  lodges  upon  the  ovary,  where  it 
develops  and  may  continue  even  to  full  term.  This  form  of  pregnancy 
has  been  called  ovarian  'pregnancy,  and  there  is  still  debate  whether  the 
pregnancy  ever  is  primary  in  the  ovary,  or  is  always  secondary  to  a 
tubal  pregnancy.  Again,  the  ovum  may  lodge  elsewhere  in  the  abdomen 
and  develop,  in  which  case  we  speak  of  the  condition  as  abdominal 
'pregnancy.  Abdominal  pregnancy  is  always  secondary  to  tubal  preg- 
nancy, and  is  the  result  of  tubal  abortion. 

About  half  the  tubal  pregnancies  may  not  result  in  tubal  abortion, 
but  in  tubal  rupture,  in  which  case  immediate  death  of  the  fetus  en- 
sues almost  invariably.  Tubal  rupture  is  due  to  a  great  thinning  of 
the  tube,  distended  by  the  growing  ovum,  until  the  tube  breaks,  with 
discharge  of  the  ovum  and  an  accompanying  profuse  hemorrhage. 

There  are  secondary  changes  in  the  uterus  associated  with  tubal 
pregnancy.  The  uterus  enlarges  somewhat  and  forms  a  decidua,  as 
does  the  tube.  If  the  abnormal  pregnancy  advances  far,  the  uterus 
becomes  pushed  to  one  side,  while  the  vagina  and  cervix  show  the  char- 
acteristic engorgement  of  pregnancy.  The  woman's  breasts  become 
enlarged  and  the  areolae  dark.  Such  are  the  more  common  structural 
and  tissue  changes  one  sees  in  the  case  of  ectopic  gestation.  Very 
little  imagination  is  required  to  realize  the  gravity  of  the  condition 
and  the  frightful  accident  which  it  may  precipitate — an  accident  de- 
manding prompt  and  thoroughgoing  treatment. 

The  S3rmptoms  and  diagnosis  of  extra-uterine  pregnancy  may 
be  characteristic  and  obvious,  or  the  reverse.  In  most  cases  the 
diagnosis  is  not  made  until  some  catastrophe  occurs.  Often,  at  first, 
menstruation  is  somewhat  disturbed — retarded  or  irregular;  while  in  a 
large  number  of  cases  it  ceases  altogether.  There  is  frequently  "  morn- 
ing sickness,"  and  at  times  nagging  pelvic  pain  with  faintness.  Some- 
times persistent  flowing  will  come  on  after  six  or  more  weeks  of  amen- 
orrhea— persistent  flowing,  frequently  mistaken  for  a  miscarriage 
by  the  medical  attendant.  Or  the  physician  may  discover  a  tubal  preg- 
nancy, finding  a  doughy  mass  at  one  side  of  an  empty  but  slightly  en- 
larged uterus.  At  this  stage  he  should  base  his  diagnosis  of  extra- 
uterine pregnancy  upon  the  four  cardinal  symptoms — disturbed  men- 
struation; sharp  pelvic  pain  and  faintness;  an  extra-uterine  ma-ss,  and 
an  enlarged,  empty  uterus. 

When  we  come  to  the  symptoms  and  diagnosis  of  surgical  calamity 
associated  with  tubal  pregnancy,  we  are  in  deeper  waters,  and  it 
is  with  calamity  that  the  surgeon  is  generally  concerned.  I  have  al- 
ready described  the  symptoms  of  tubal  abortion,  which  are  notably  pain 
of  an  endurable  character,  but  prolonged  and  distressing,  extreme 
faintness,  and  the  evidences  of  internal  hemorrhage — rapid,  thready 
pulse,  cold  extremities,  blanched  aspect,  distended  and  tender  abdo- 


342  FEMALE   ORGANS  OF  GENERATION 

men,  dyspnea,  and  subnormal  temperaturo ;  or  all  these  symptoms  may 
be  present,  but  in  milder  degree.  Generally,  a  mass  may  be  felt  in  the 
pelvis  if  the  patient  be  not  too  fat  or  too  tender  for  a  proper  physical 
examination.  Usually,  blood  is  seen  to  escape  from  the  os  uteri. 
Even  with  these  signs  the  surgeon  may  be  unable  to  determine  accur- 
ately the  nature  of  the  accident  that  has  occurred,  but  he  sees  that 
a  grave  abdominal  emergency  demanding  o])eration  is  before  him. 

The  syniptot)is  of  tubal  rupture  are  more  alarming  even.  The  most 
obvious  phenomena  are  the  agony  and  prostration  of  the  woman.  Once 
witnessed,  the  scene  cannot  be  forgotten:  the  blanched,  exhausted 
patient,  moaning  or  screaming  in  agon}',  writhing  and  involuntarily 
and  uselessly  attempting  to  discharge  her  load  by  frantic  straining. 
The  crisis  passes  in  a  few  minutes,  or  may  last  several  hours.  The 
rending  of  the  tube  ceases.  Pain  becomes  less,  but  hemorrhage  does 
not  stop  at  once,  and  a  condition  of  almost  pulseless  exhaustion  super- 
venes. We  know  that  a  great  amount  of  blood  has  been  poured  out 
into  the  abdomen  or  extraperitoneally  between  the  folds  of  the  broad 
ligament.  The  patient  may  be  so  exsanguinated,  and  the  heart  so 
exhausted,  that  bleeding  ceases  spontaneously  for  a  time,  but  we  never 
know  how  soon  the  heart  may  revive  or  how  soon  a  second  and  a  third 
hemorrhage  may  ensue. 

Such  are  the  calamities — tubal  abortion  and  tubal  rupture — com- 
monly resulting  from  extra-uterine  pregnancy.  A  rare  outcome  of 
the  condition  is  the  expulsion  into  the  abdomen  of  a  living  fetus  which 
lodges,  grows,  develops,  and  reaches  full  term,  or  an  age  approximat- 
ing to  full  term.  The  fetus  then  dies,  the  placenta  becomes  detached 
and  disintegrates,  while  the  fetus,  as  a  foreign  body,  may  be  carried  for 
years  by  the  mother;  it  may  become  disorganized  or  calcified  (litho- 
pedion) ;  it  may  form  a  focus  of  infection,  and  portions  of  it  may 
penetrate  the  hollow  viscera  and  be  discharged  through  the  rectum  or 
vagina  or  through  the  abdominal  wall  even. 

Such,  in  extremely  brief  detail,  is  the  story  of  extra-uterine  preg- 
nancy, and  the  student  will  realize  the  grave  difficulties  which  encouter 
him  when  he  comes  to  consider  treatment. 

Treatment. — In  those  earliest  stages  of  which  I  spoke,  if  the  pres- 
ence of  an  extra-uterine  pregnancy  is  fairly  well  determined,  the  one 
and  only  course  for  the  surgeon  is  operation.  Open  the  abdomen  and 
remove  the  enlarged  tube.  The  operation  at  this  stage  is  simple  and 
the  danger  no  greater  than  the  removal  of  a  chronically  inflamed  tube. 
I  have  already  described  the  technic.  In  the  case  of  the  alarming 
symptoms  associated  with  tubal  abortion  or  rupture,  operation  is  also 
imperative,  but  the  moment  for  doing  the  operation  is  not  always  ob- 
vious. Indeed,  surgeons  still  debate  the  question.  A  few  years  ago 
all  were  agreed  that  immediate  operation  was  as  urgent  in  all  cases  as 
though  the  patient  was  suffering  from  gunshot  of  the  intestines.  We 
have  modified  somewhat  this  view  with  time,  and  the  mode  of  apply- 
ing that  modification  depends  entirely  upon  the  experience  and  intelli- 
gence of  the  individual  surgeon.     If  the  woman  be  recently  collapsed, 


TUBAL   PREGNANCY  343 

if  pain  be  still  present  and  the  pulse  fair, — 120  or  under, — I  believe  one 
should  immediately  o])en  the  aljdomcn  and  control  the  hemorrhage. 
On  the  other  hand,  if  the  patient  be  in  profound  shock  and  almost  pulse- 
less, one  knows  that  a  severe  surgical  operation  may  turn  the  scale 
and  kill  the  victim.  What,  then,  shall  the  surgeon  do?  Fortunately,  we 
have  learned  from  much  experience  that  most  women  do  not  die  at  once 
under  these  alarming  conditions — that  hemorrhage  spontaneously  ceases 
and  that  the  heart  rallies.  I  do  not  think  it  safe  actively  to  stimulate 
such  patients  except  that  I  sometimes  give  a  hypodermic  injection  of 
strychnin  (e'o  or  :jV  gr.)  and  watch  closely  the  result.  Of  all  things, 
give  no  saline  infusions.  In  any  event,  we  usually  see  the  patient  rally 
slo^\ly  from  the  condition  of  extreme  shock.  Then  we  know  that 
hemorrhage  has  ceased  temporarily,  and  that  if  we  stand  by,  ready  to 
operate  at  a  moment's  notice,  the  proper  time  will  soon  arrive.  I  have 
thus  waited  tw^o,  three,  and  four  hours,  and  am  convinced  that  in  the 
case  of  persons  suffering  from  extreme  shock  waiting  is  often  the  wiser 
course.  In  other  words,  catch  your  patient  on  the  rebound,  when  you 
may  operate  and  save  her  life.  I  submit  that  there  are  few  surgical 
emergencies  calling  for  greater  tact,  resourcefulness,  judgment,  and 
swift  technical  skill. 

The  method  of  the  operation  is  simple.  With  the  patient  in  the 
Trendelenburg  position,  open  quickly  through  the  rectus  muscle  over 
the  affected  side,  sweep  back  the  intestines,  seize  the  uterus  with  double 
hooks,  draw  it  into  the  wound,  and  clamp  the  ruptured  tube  at  both 
ends.  Then  remove  the  tube  in  the  fashion  I  have  described,  scoop  out 
blood-clots  and  the  products  of  conception,  wash  out  quickly  the  ab- 
domen with  an  abundant  hot  saline  douche,  close  the  w^ound,  and  put  the 
patient  back  to  bed  as  soon  as  possible.  There  may  or  may  not  be  ad- 
ditional shock.  Give  a  stimulating  enema  of  black  coffee,  brandy,  and 
salt  solution,  and  repeat  the  salt  solution  (10  ounces)  every  four  hours 
for  twenty-four  hours;  inject  strychnin  carefully,  and  elevate  the  foot 
of  the  bed.  The  great  majority  of  these  patients  recover  if  they  come  off 
the  table  alive.  Those  patients  who  die  perish  at  once  as  the  result  of 
an  operation  undertaken  in  extremis.  It  is  gratifying  to  watch  the 
rapid  convalescence  of  these  women  and  their  prompt  restoration  to 
health. 

The  treatment  of  extra-uterine  pregnancy  advanced  to  the  rare  con- 
dition of  full  term  is  another  problem.  The  fetus,  its  placenta,  and  mem- 
branes are  by  that  time  implanted  somewhere  in  the  abdominal  cavity 
outside  of  the  tube,  and  can  be  removed,  if  at  all,  by  abdominal  section 
only.  It  is  a  simple  matter  to  open  the  abdomen  and  remove  the  child, 
but  the  extraction  of  the  placenta  is  a  frightfully  hazardous  proceeding, 
on  account  of  the  inevitable  hemorrhage  which  follows.  Be  it  remem- 
bered that  the  loosening  and  removal  of  the  placenta  from  the  normal 
gravid  uterus  is  relatively  bloodless  because  the  uterus  contracts  and 
shuts  up  its  great  vessels.  On  the  other  hand,  when  the  placenta  is 
attached  to  some  non-contractile  portion  of  the  abdomen,  its  removal  is 
not  followed  by  closure  of  the  vessels,  so  that  excessive  hemorrhage 


344  FEMALE    ORGAXS   OF   GEXEKATIO!': 

results.  Commonly,  such  an  C('to]jic  placenta  rocoivos  its  bloo(l-sup])ly 
through  some  portion  of  the  uterus  and  adnexa,  so  that  it  -woukl  appear 
as  though  control  of  uterine  and  ovarian  arteries  would  check  hemor- 
rhage from  the  placental  site.  Unfortunately,  there  is  often  a  copious 
collateral  blood-supply  to  the  placenta,  so  that  the  ligation  of  uterine 
and  ovarian  arteries  avails  little.  Removal  of  an  extra-uterine  fetus  is, 
therefore,  one  of  the  most  hazardous  undertakings  in  surgery — to  be 
attempted  by  the  most  skilful  operator  only,  who  may  be  obliged  to 
compress  the  aorta  in  order  to  control  hemorrhage.  P'or  this  rea.son  I 
recommend  the  easier  and  safer  method  of  removing  the  child,  stitching 
the  sac  into  the  wound,  packing,  and  leaving  the  })lacenta  to  dislodge 
itself  later. 

These  children,  if  they  survive,  may  be  as  vigorous  as  those  born  in 
the  natural  manner. 

PELVIC  HEMATOCELE 

Pelvic  hematocele  was  formerly  the  term  applied  to  most  collections 
of  blood  within  the  pelvic  cavity — pelvic  hematocele  and  hematosalpinx. 
We  are  now  assured  that  a  majority  of  cases  of  j^elvic  hematocele  and 
hematosalpinx  are  due  to  tubal  pregTiancy.  Such  collections  of  blood 
may  be  within  the  folds  of  the  broad  ligament,  as  I  have  described,  and 
may  burrow  under  the  peritoneum  in  various  directions,  or  the  blood 
may  be  free  in  the  pelvic  cavity.  We  formerly  practised  vaginal  sec- 
tion in  order  to  clear  out  such  hemorrhagic  collections,  but  of  late  j-ears 
we  are  convinced  that  the  best  practice  is  to  open  from  above,  so  as 
quickly  and  sureh'  to  explore,  to  control  hemorrhage,  and  to  remove 
thoroughly  all  the  products  of  gestation. 


CHAPTER  XII 

PERINEUM  AND  VAGINA 

Surgical  interest  in  the  female  perineum  centers  in  the  treatment 
of  its  childbirth  lacerations.  There  are  numerous  other  perineal  lesions, 
but  they  are  mostly  simple  disturbances  easily  treated. 

At  the  beginning  of  Chapter  X  some  mention  was  made  of  the  anat- 
oni}'  of  the  perineum,  and  it  is  well  to  repeat  here  the  statement  that, 
by  the  surgeon,  the  perineum  must  constantly  be  regarded  as  a  floor, 
ingeniously  constructed  to  support  the  pelvic  and  abdominal  organs. 
Damage  to  this  floor  means  displacement  of  organs,  and  often  a  far- 
reaching  course  of  ailments,  such  as  I  have  already  described  in  speak- 
ing of  uterine  displacements  and  other  ptoses  of  the  abdominal  organs. 
It  remains  for  us  now  to  consider  means  of  repairing  damage  to  the  per- 
ineum. I  pointed  out  in  Chapter  X  also  how  the  structures  of  the 
perineum  are  divided  into  superficial  and  deep  layers.  It  is  laceration 
of  the  deep  layer  which  calls  most  urgently  for  surgical  aid.  Damage 
to  the  superficial  layer  results  in  local  discomfort  onty. 

PERINEAL   LACERATIONS 

The  leading  feature  of  deep  perineal  damage  is  laceration  of  the 
levator  ani  muscle — the  great  muscle  which  supports  the  pelvic  viscera. 
Until  recent  years  we  failed  to  appreciate  the  significance  of  tears  of 
this  deep  muscle,  so  that  the  old-time  operations  for  repair  of  the  per- 
ineum were  directed  to  the  reconstruction  of  damaged  superficial  parts — 
the  skin,  the  fourchet,  and  sometimes  the  sphincter  ani.  Reynolds  ^ 
showed,  years  ago,  the  form  and  character  of  fresh  perineal  lacerations 
and  the  mechanism  of  these  lesions.  As  seen  immediately  after  child- 
birth, the  tear  is  somew^hat  Y-shaped,  crescentic  in  the  vagina,  with  a 
single  prolongation  through  the  labia.  The  crescentic  portion  of  the 
tear  is  that  which  penetrates  deeply  through  the  levator  ani  muscle; 
the  downward  prolongation  divides  the  skin  and  the  sphincter  ani 
even.  A  result  of  extensive  tears  of  this  nature  is  a  relaxation  and 
do^^-Lward  sagging  of  the  pelvic  floor,  with  the  superimposed  organs. 

Treatment. — A  description  of  the  popular  operations  for  repair  of 
the  lacerated  perineum  would  necessitate  a  long,  complicated  historic 
essay,  suitable  for  a  special  text-book  only.  Let  us  study  the  simple  and 
effective  operation  which  I  favor  especially,  and  then  mention  one  or  two 
of  the  other  better  known  procedures.  For  a  more  clear  understanding 
of  the  purpose  of  perineal  repair  let  me  again  remind  the  reader  that 
laceration  of  the  levator  ani  makes  for  not  only  uterine  displacement 
1  Edward  Reynolds,  Trans.  Amer.  Gyn.  Soc,  September,  1891. 

345 


346 


FEMALE  ORGANS  OF  GENERATION 


.2I^ 

'j^^m_            ^ 

1 

1 

1 

1 

1 
1 

7n>  £  h  0.  ;a  ^  T-.i^,  ft .  _ 

j_i 

■or 

Fig.  214. — Cystocele  and  rectocele. 


Fig.  215. — Flap-splitting  operation  for  repair  of  perineum — step  1  (redrawn  after 

Aitken). 


PERINEAL   LACERATIONS 


347 


and  descent,  but  also  for  sagging  forward  of  the  anterior  rectal  wall 
(reckx'cle),  and  sagging  backward  and  downward  of  the  bladder  (cys- 
toc'cle).  The  operation  which  1  shall  now  describe  remedies  in  great 
measure  both  rectocele  and  cystocele. 

By  the  following  operation  we  aim  primarily  to  seek  out  and  stitch 
together  the  ruptured  fibers  of  the  levator  ani;  to  this  end,  split  the 
septum  between  the  vagina  and  rectum  through  a  crescentic  incision 
drawn  around  the  lower  border  of  the  vagina  or  just  within  the  vagina. 
The  lateral  portions  of  this  cut  enter  readily  through  the  skin  and  super- 
ficial fascia,  and  open  the  ischiorectal  fossa.      So  far  there  is  no  diffi- 


Fig.  216. — Repair  of  perineum — step  2  (redrawn  after  Aitken). 


culty,  but  the  separation  in  the  median  line,  between  the  vagina  and 
rectum,  often  demands  a  painstaking  and  laborious  dissection  through 
a  great  amount  of  tough  scar  tissue.^  By  keeping  close  to  the  vaginal 
flap,  however,  one  may  avoid  opening  the  rectum^an  awkward  com- 
plication. When  the  scar  tissue  has  been  dissected  through,  the  vagina 
and  rectum  peel  apart  readily,  and  then  quickly  with  the  fingers  one 
deepens  the  wound  if  needful  up  to  the  uterine  cervix.     There  is  not  the 

1  Tliis  operation  is  in  many  respects  that  practised  by  Lawson  Tait  twenty-five 
years  ago,  and  still  described  as  Tait's  operation  in  many  of  the  text-books.  I  recog- 
nize it  as  Tait's  operation,  but  on  carefully  reviewing  liis  description  cannot  find 
that  he  carried  his  dissection  as  deep  as  I  feel  generally  to  be  advisable. 


348 


FEMALE  OUGAXS  OF  GENERATION' 


slightest  danger  of  entering  the  peritoneal  cavity.  Often  there  is  trou- 
blesome bleeding  from  large  hemorrhoidal  veins,  which  should  be  care- 
fully secured  as  one  progresses.  The  whole  wound  should  be  made  as 
dry  as  possible,  though  the  checking  of  all  oozing  is  not  easy. 

^^'ith  the  depth  of  the  wound  now  exposed  and  the  sides  held  widely 
apart  with  retractors,  one  sees  or  palpates  readily  the  strong  edges  of 
the  divided  levator  ani  muscle.  The  rest  of  the  o])eration  consists  in 
placing  the  stitches  properly  and  securely.     For  this  the  operator  must 


Fig.  217. — Repair  of  perineum — step  3  (redrawn  after  Aitken). 


now  sacrifice  his  left  forefinger  by  introducing  it  into  the  rectum  to  act 
as  a  guide  for  the  needle.  Three  or  four  heavy,  deep,  absorbable, 
buried  catgut  stitches  are  enough  to  unite  the  edges  of  the  torn  muscle. 
One  may  use  the  kangaroo  tendon,  chromicized  catgut,  or  the  catgut 
prepared  by  Bartlett's  method,  which  I  prefer.  The  torn  edges  of  the 
levator  ani  muscle  can  be  most  effectively  approximated  b}-  inserting 
figure-of-8  stitches.  Having  tied  these  deep  stitches,  a  second  row  of 
lighter  buried  stitches  is  passed  to  bring  together  the  more  superficial 


no  H  IN  10  A  I.    LACERATIONS 


349 


parts.  If  the  sphincter  aiii  Ik;  torn,  the  lowermost  of  these  stitches  may- 
be piissctl  deeply  throii<i;h  the  tissues  on  either  side  of  the  anus,  so  as  to 
bring  together  tlie  portions  of  that  niuscJe.  I  sew  up  the  skin-edges, 
and  the  loose  vaginal  flap  which  results  from  the  dissection,  with  in- 
terrupted silkworm-gut  stitches,  leaving  the  ends  long,  and  tying  to- 
gether in  one  sheath  all  the  loose  ends  so  as  to  prevent  the  intolerable 
irritation  of  the  skin  which  would  otherwise  result.  This  comparatively 
simple  method  of  perineorrhaphy  has  sufficed  in  my  experience  for 
perineal  lacerations  of  every  degree, — a  mere  tear  of  the  skin,  a  lacera- 
tion extending  to  the  sphincter,  and  a  laceration  complete  to  the  rectum, 


V- 


Fig.  218. — Repair  of  perineum — step  4  (redrawn  after  Aitken). 

— but  obviously  the  extent  of  the  dissection  will  be  in  proportion  to  the 
tear  with  which  one  is  dealing. 

It  is  bbvions  at  once  that  this  operation,  thoroughly  performed, 
builds  up  a  stout  perineal  body  and  cures  rectocele.  In  many  cases  a 
prolapsed  bladder  is  thus  supported  at  the  same  time,  as  well  as  a  falling 
uterus.  In  extreme  cases,  should  cystocele  and  uterine  descent  per- 
sist, the  surgeon  must  supplement  this  operation  by  suspending  the 
uterus;  and  in  the  case  of  a  long  cervix,  tending  to  bore  through  the 
new,  narrowed  vaginal  passage,  he  may  amputate  the  neck  of  the  womb. 
I  advise  the  student  to  read  over  the  description  of  operations  for 
procidentia  (Chapter  X)  in  connection  with  this  subject. 


350 


FEMALE  ORGANS  OF  GENERATION 


The  general  practitioner  unci  obstetrician  will  be  interested  to  know 
that  I  have  observed  a  number  of  women  who  have  become  pregnant 
and  borne  children  subsequent  to  this  operation  on  the  perineum. 
In  every  case  the  vagina  opened  well  before  the  advancing  fetal  head, 
and  secondary  lacerations  were  inconsiderable. 

The  familiar  Emmet  operation  for  ruptured  perineum  is  based  on 
the  principle  that  by  denuding  superficially  the  scar  tissue  about  the 
vaginal   outlet,   the   rupture    may  be   returned    to   the   condition   in 


Jf.O.Hui.i-r-.., 


^' 


Fig.  219. — Repair  of  perineum— step  5  (redrawn  after  Aitken). 

which  it  existed  when  fresh,  immediately  after  the  childbirth.  After 
denuding,  the  surgeon  binds  together  the  wounded  edges  with  silver 
sutures.  This  operation  is  applicable  to  slight  tears  only.  The  dis- 
section does  not  reach  the  deep  parts,  so  that  the  result,  though  pre- 
senting a  seemh^  cosmetic  scar,  is  of  little  value  as  a  perineal  support 
and  yields  at  once  in  the  case  of  a  subsequent  labor. 

Noble's  operation  also  is  based  on  the  principle  of  denudation,  but 
the  dissection  is  carried  further,  as  shown  by  the  illustration,  so  that  an 
admirably  strong  perineal  support  is  secured. 


PERINEAL    LACERATIONS 


351 


Among  the  well-known  operations  on  the  perineum  are  those  of 
Martin,  Dudley,  Cleveland,  Garrigue,  Outerbridge,  Reed,  Goldspoon, 
and  others. 

The  after-treatment  for  all  these  operations  is  of  great  importance. 
It  consists  of  rest  in  bed  for  at  least  sixteen  days,  careful  regulation 
of  this  bowels,  and  painstaking  care  of  the  wound,  as  after  a  childbirth. 
The  bowels  should  be  moved  with  an  oil  enema  on  the  second  or  third 
day.  If  the  patient  voluntarily  passes  urine,  the  parts  should  be  cleansed 
with  an  aseptic  douche  after  each  micturition. 


Fig.   220. — Noble's   operation   for   repair   of   perineum. 


The  stitches  may  be  removed  on  the  tenth  day.  At  the  end  of  two 
weeks  the  patient  may  sit  up  in  bed,  but  should  not  be  allowed  to 
stand  until  the  expiration  of  three  weeks.  After  the  bowels  have  moved, 
a  liberal  diet  may  be  allowed,  with  the  use  of  laxatives  or  enemata  to 
insure  a  comfortable  daily  evacuation  of  the  rectum. 

Lacerations  of  the  perineum  hold  so  conspicuous  a  place  in  the  sur- 
gery of  these  parts  that  students  often  overlook  a  consideration  of  other 
local  surgical  lesions.  There  are  sundry  other  such  lesions,  more 
infrequent  than  perineal  rupture,  but  often  distressing  and  important 


352 


FEMALE  OUGAXS  OF  GEXERATION 


to  the  sufferer.  These  are  wounds,  fistula',  tumors,  cysts,  and  the  lesions 
of  venereal  disease.  A  common  and  apparently  trifling  disturbance  is 
urethral  caruncle. 

URETHRAL  CARUNCLE 

This  is  an  outgrowth  at  the  orifice  of  the  urethra.  There  are  two 
forms  of  caruncle — the  first  is  a  capillary  aneurysmal  varix  covered 
with  nmcosa,  producing  a  bright  red,  erectile  swelling  at  the  inferior 

margin    of    the    meatus.      The 
(rfu,nj-,'  J.  second  form  is  of  the  nature  of  a 

small  hemorrhoid,  a  varicose  con- 
dition of  the  urethral  nmcous 
membrane.  The  former  type  of 
carvmcle  is  the  more  common. 
It  develops  in  middle  life  usually. 
The  symptoms  are  distressing 
often.  The  patient  complains 
bitterly  of  scalding  when  she 
passes  water,  and  often  of  a 
burning,  throbbing  sensation  for 
some  time  after  the  completion 
of  the  act.  If  untreated,  the 
caruncle  persists,  often  growing 
larger  and  more  irritating  with 
time. 

Treatment  is  simple  and  ef- 
fective.    With  the  patient  under 
ether  (sometimes  cocainwall  suf- 
fice) ,  seize  the  little  tumor  gently 
with  right-angled  forceps,  snip  it 
off  with   scissors,  and  touch  the 
base  with  the  Paquelin  cautery. 
Some  surgeons  prefer  to  remove 
the  tumor  entirely  by  the  cautery. 
Stitch  together,  with  fine  catgut, 
the  severed  mucous  edges.     The 
patient  recovers  in  a  few  days, 
though  there  may  be  some  pain,  at  first,  on  passing  urine.     For  three 
or  four  days  after  the  operation  the  parts  should  be  bathed  carefully 
with  sterile  water  after  each  micturition. 


JT-OHut-jT' 


Fig.  221. — Urethral  caruncle. 


THE  VULVA 

We  need  not  concern  ourselves  here  with  wounds  of  the  vulva, 
which  call  for  the  same  treatment  as  similar  wounds  elsewhere.  In- 
flammations of  the  vulva  (erysipelas  and  diphtheria  especially) 
should  receive  the  treatment  appropriate  to  such  inflammations. 
Tuberculosis  of  the  vulva  is  frequently  a  part  of  a  general  tuberculosis, 
and  calls  for  constitutional  treatment.     Syphilis  nmst  be  treated  con- 


VAGIXAL   FISTUL.E  353 

stitutionally  with  mercury  and  the  ioclids.  Elephantiasis  and  atrophy 
call  for  no  special  mention;  and  skin  diseases  fall  within  the  depart- 
ment of  dermatolog}'. 

Tumors  of  the  vulva  are  not  especially  common,  and  fall  into  the 
general  classes  of  malignant  and  benign  growths,  such  as  fibromata, 
which  may  reach  a  considerable  size,  polypi  and  lipomata,  rare  afflic- 
tions. 

Careinoma  of  the  vulva  is  not  infrequently  seen — carcinoma,  spring- 
ing from  the  skin  or  mucous  surfaces  of  the  labia,  and,  rarely,  from  the 
clitoris.  Extirpation  often  promises  well,  for  metastases  are  uncommon. 
Sarcoma  of  the  vulva  is  extremely  rare.  Both  round-cell  and  spindle- 
cell  varieties  are  recorded,  as  well  as  melanosarcoma  and  myxosar- 
coma.    Excision  is  the  only  treatment,  but  the  prognosis  is  always  bad. 

There  are  varices  of  the  vulva,  comparable  to  varicocele  in  the 
male,  to  be  treated  by  extirpation  of  the  veins;  and  cysts  developing 
commonly  from  the  glands  of  Bartholin  or  from  Gartner's  duct.  These 
cysts,  too,  must  be  extirpated. 

THE  VAGINA 

Vaginal  lesions  suitable  for  the  surgeon's  consideration  are  common 
enough,  and  far  the  most  numerous  of  these  lesions  are  those  chie  to 
childbirth.  The  ordinary-  posterior  tears  of  the  vagina  are  associated 
commonly  with  ruptures  of  the  perineum,  and  those  I  have  already 
discussed.  Almost  equally  important  and  far  more  difficult  of  treat- 
ment are  vaginal  fistulae. 

VAGINAL  FISTULA 

These  fistulae  are  found  in  a  variety  of  situations,  and  you  will 
encounter  them  in  every  general  surgical  ward  as  well  as  in  the  service 
of  the  gynecologist  proper.  They  are  due,  usually,  to  pressure  necrosis, 
resulting  from  a  too  long  delay  of  the  child's  head  during  labor,  and 
not  to  the  use  of  forceps.  Rather  are  they  due  to  a  delay  in  the 
use  of  forceps.  The  figures  show  such  fistulse.  The  most  com- 
mon is  vesicovaginal  fistula.  More  rarely  one  finds  rectovaginal 
fistula,  vesico-uterine  fistula,  vesico-utero vaginal  fistula,  and  urethro- 
vaginal fistula.  The  literature  of  vaginal  fistula  is  enormous,  for  the 
problem  was  worked  out,  and  its  therapeutics  put  upon  a  sound  basis, 
by  Sims  and  Emmet,  two  of  the  greatest  lights  in  American  gynecology. 
The  cure  of  vesical  fistula  is  in  the  field  of  major  surgery  often.  Opera- 
tions are  difficult,  tedious,  perplexing,  and  sometimes  disappointing, 
while  the  condition  to  be  relieved  is  extremely  serious. 

I  have  said  that  childbirth  is  the  common  cause  of  these  fistulse. 
Other  causes  are  opening  of  the  bladder  by  the  surgeon  for  cystitis  or 
for  the  removal  of  calculi.  Accidental  traumatism  may  result  in  fistula. 
Rarely,  there  may  exist  congenital  fistula,  or  fistula  may  arise  from 
sundry  ulcerative  processes,  from  the  pressure  of  a  neglected  pessary, 
from  syphilis,  from  cancer. 
23 


354 


FEMALE  ORGANS  OF  GENERATION 


The  symptoms  of  urinary  fistula  are  fairly  characteristic,  and  the 
diagnosis  generally  is  easy.  There  is  a  quite  constant  dribbling  of 
urine,  especially  when  the  patient  stands.  If  the  urine  is  passed  reg- 
ularly and  freely  by  the  urethra  at  the  same  time  that  it  leaks  from  the 
vagina,  one  looks  for  a  urethrovaginal  fistula.  These  fistula'  cause 
cystitis  often,  while  the  leaking  urine  excoriates  the  vaginal  mucous 
membrane  and  the  skin,  and  forms  deposits  of  salts  on  the  ulcerated  sur- 
faces. One  confirms  the  diagnosis  by  digital  examination  and  by  in- 
spection. Frequently  a  probe  may  be  passed  thi-ough  the  urethra  and 
be  received  upon  the  examining  finger  in  the  vagina. 

The  treatment  of  vesicovaginal  fistula  is  operative,  though  oc- 
casionally a  small  fresh  fistula  may  close  spontaneously.     The  operable 

cases  may  be  divided  into  two 
classes:  small  fistula?  with  a  slight 
amount  of  cicatricial  tissue  about 
them;  and  large,  broadly  indurated 
fistula. 

The  small  fistulse  may  be  closed 
often  by  simply  refreshing  the  edges 
of  the  vaginal  side  down  to  the  blad- 
der mucosa,  and  sewing  up  the  fresh 
wound  with  silkworm-gut  stitches, 
taking  care  that  there  be  no  tension 
on  the  flaps;  but  in  case  there  is 
much  induration  and  thickening 
about  the  fistula,  a  period  of  pre- 
paratory treatment  should  be  given. 
This  preparatory  treatment  consists 
in  keeping  the  urine  acid  for  two  or 
three  weeks  before  operation,^  so  as 
to  limit  the  amount  of  the  deposits, 
and  douching  the  vagina  with  a  simple  antiseptic  three  or  four  times 
daily.  Sometimes  it  is  necessary  to  scrape  off  the  deposits  and  to  touch 
the  excoriated  surfaces  with  nitrate  of  silver.  At  the  same  time  cys- 
titis must  be  combated  with  boric-acid  bladder  douches,  and  vesical 
calculi  must  be  removed. 

When  this  course  of  treatment  has  been  pushed  as  far  as  seems  best, 
the  surgeon  may  proceed  with  the  operation.  Place  the  patient  in 
Sims'  position  and  retract  the  perineum  with  a  Sims'  speculum.  Denude 
the  vaginal  surface  so  as  to  make  the  wound  lie  longitudinally,  in  the 
course  of  the  vaginal  canal;  work  gently,  holding  the  flaps  with  bullet 
forceps  and  cutting  with  a  sharp,  curved  scissors.  Sew  up  with  silk- 
worm-gut, and  leave  the  suture  ends  hanging  outside  the  vulva.  The 
after-treatment  is  important.  Constant  bladder  drainage  should  be 
provided;  the  vagina  should  be  kept  lightly  packed  with  gauze;  drink- 
ing of  the  acid  mixture  should  be  continued,  while  drinking-water  should 

1  To  render  the  urine  acid,  use  Emmet's  mixture:  benzoic  acid,  2  drams; 
borax,  3  drams;  cinnamon  water,  12  ounces;  a  tablespoonful  diluted  four  times  daily. 


Fig.  222.— Vesicovaginal  fistula   (dia 
grammatic). 


VAGINAL    FISTUL.E 


355 


be  supplied  copiously.  The  bowels  should  be  regulated  carefully. 
The  stitches  should  remain  in  place  for  at  least  twelve  days.  With  all 
these  precautions  even,  union  may  not  always  take  place,  and  a  slight 
fistula  may  recur.  In  such  case,  on  three  occasions,  I  have  finally  and 
satisfactorily  closed  the  trifling  leak  by  injecting  melted  paraffin  into 
the  tissues  about  the  fistula,  thus  bringing  about  union  by  pressure. 

The  second  form  of  vesicovaginal  fistula — the  great  irregular, 
indurated  opening — demands  often  a  serious  and  extensive  operation. 
A  number  of  different  methods,  many  of  them  extremely  ingenious, 
have  been  devised,  such  as  these  of  R^'dygier,  IMartin,  Trendelenburg, 
Sanger,  Walcher,  von  ^yinkel,  Mackenroth,  Kelly,  Kiistner,  and  others. 
Kelly  describes  the  details  of  these  procedures,  and  I  refer  the  reader 


Fig.  223. — Suprapubic  operation  for  vesicovaginal  fistula  (.Trendelenburg),  sagittal 
section.    Suprapubic  incision  seen  above  (Kelly) . 

to  his  Operative  Gynecology,  vol.  i,  p.  336.  For  myself  I  have  secured 
gratifying  results  through  the  employment  of  von  Dittel's  method,  which 
follows  the  principle  of  all  the  others ;  that  is  to  say,  by  some  means  one 
separates  the  bladder  from  the  vagina  and  repairs  the  several  rents  of 
the  organs  independently.  I  advocate  opening  down  upon  the  bladder 
from  above  the  pubes  and  isolating  the  bladder  without  opening  the 
peritoneum  if  possible.  Often  this  is  possible,  but  if  not,  one  must  go 
through  the  abdominal  cavity,  and  in  any  case  the  dissection  is  facili- 
tated by  tipping  up  the  patient  on  a  Trendelenburg  table. 

Rectovaginal  fistula  is  less  common  than  vesicovaginal  fistula, 
but  it  is  even  more  distressing.  The  diagnosis  is  readily  made  by  ob- 
serving the  contents  of  the  rectum  oozing  from  the  vagina.     The  patient 


356 


FEMALE  ORGANS  OF  GENERATION 


herself  also  will  observe  often  the  uncontrollable  escape  of  gas.  The 
treatment  of  this  condition  is  difficult,  and  repeated  operations  may  be 
required.  The  old  operation  of  Sims — the  refreshing  and  sewing  together 
of  the  edges  of  the  fistula — rarely  is  successful.  I  have  employed  satis- 
factorily two  somewhat  similar  operations.  When  the  fistula  is  close 
to  the  outlet  of  the  vagina,  split  the  rectovaginal  septum  in  a  fashion 
similar  to  the  method  employed  in  Tait's  operation  for  ruptured  per- 
ineum. Then,  through  this  liberal  opening,  one  refreshes  the  edges  of 
the  fistula  on  both  vaginal  and  rectal  sides  and  sews  up  the  openings 
independently.  In  closing  the  rectal  portion  of  the  septum  use  buried 
catgut  sutures  and  take  pains  not  to  penetrate  the  rectal  nmcosa.  Then 
close  the  vaginal  portion  of  the  septum  with  silkworm-gut  stitches, 
inserted  from  the  vaginal  surface.  If  the  fistula  be  too  high  up  to  per- 
mit of  this  simple  operation,  one  may  employ  the  technic  of  Lauenstein, 


Fig. 


224. — Rectovaginal 
gramma  tic). 


fistula    (dia- 


Fig.  225. — Repair  of  rectovaginal  fistula. 
Lauenstein's  operation  (after  Dudley). 


which  is  similar  in  principle  to  the  foregoing.  Having  carefully  refreshed 
the  edges  of  the  fistula,  split  the  vaginal  mucosa  longitudinally  at  either 
end  of  the  fistula,  and  thus  turn  back  liberal  vaginal  flaps.  By  this 
means  the  rectal  wall,  with  its  fistulous  opening,  is  exposed.  Then  sew 
up  the  rectal  wall  with  catgut  stitches,  and  complete  the  operation  by 
drawing  over  it  independently  the  refreshed  vaginal  flaps,  which  must 
carefully  be  sutured  into  place. 

Noble  quotes  with  approval  Dudley's  ingenious  operation  for  repair 
of  rectovaginal  fistula  opening  high  in  the  vagina.^  B}^  this  operation 
the  rectum  is  dissected  free  from  the  surrounding  tissues  by  the  surgeon 
working  through  the  anus.  Having  freed  the  rectum  up  to  and  beyond 
the  fistula,  the  operator  then  pulls  the  gut  outside  of  the  sphincter  until 
the  rectal  fistula  is  exposed.  He  then  cuts  off  the  bowel  above  the  fis- 
^  G.  H.  Noble  in  Bovee's  Practice  of  Gynecology,  p.  132. 


ATRESIA    OF   THE    VAGINA  357 

tula  and  stitches  the  rectal  stump  to  the  skin.  The  hole  left  in  the 
vagina  no  longer  communicates  with  the  rectum  and  may  now  be  closed 
or  not,  according  to  its  extent  and  involvement.  Recently  I  succeeded 
in  closing  a  rather  fresh  rectovaginal  fistula  by  giving  the  patient  ap- 
propriate opsonic  vaccines,  which  had  the  effect  of  stimulating  the 
wound  and  causing  a  bridging  over  of  the  considerable  rent  with  granu- 
lations. 

INFLAMMATION 

Vaginitis  need  not  detain  us  further  than  to  remark  that  the  majority 
of  vaginal  inflammations  are  gonorrheal  in  origin  and  call  for  treatment 
appropriate  to  gonorrhea. 

VAGINAL  CYSTS 

Vaginal  cysts  occasionally  spring  from  the  remains  of  the  Wolffian  or 
Gartner's  ducts.  Benign  and  malignant  tumors  also  arise  in  the  vagina. 
A  consideration  of  these  rare  conditions  would  mean  a  repetition  prac- 
tically of  much  of  Chapter  X.  Extirpation  through  the  vagina  of  such 
tumors  is  the  only  logical  treatment. 

ATRESIA  OF  THE  VAGINA 

Atresia  of  the  vagina  means  closure  of  that  canal,  and  is  a  somewhat 
infrequent  condition.  The  closure  may  be  complete  or  partial,  and, 
according  to  the  extent  of  the  obstruction,  menstruation  and  inipreg- 
nation  may  or  may  not  occur.  The  causes  of  atresia  are  defects  in  the 
fusion  of  the  MulJerian  ducts  and  canalization  of  the  original  cellular 
mass  forming  the  rudimentary  vagina.  The  upper  extremity  of  the 
canal  is  the  portion  commonly  thus  deformed.  Traumatism  may  be 
the  cause  of  atresia.     The  diagnosis  is  readily  made  by  inspection. 

The  only  treatment  is  operative,  and  the  nature  of  the  operation 
must  vary  with  the  character  and  the  origin  of  the  condition.  In  con- 
genital cases  the  examination  should  be  made  with  finger  in  the  rectum 
and  sound  in  the  bladder.  Ordinarily,  the  operation  consists  in  incising 
the  obstruction  in  several  places  and  distending  and  packing  the  vagina 
with  iodoform  gauze  until  healing  is  accomplished.  Numerous  writers 
advocate  sundry  radical  measures.  When  the  lesion  is  extensive  and 
impossible  to  overcome  by  simple  incisions,  sometimes  it  is  necessary 
to  remove  the  uterus  even,  or  at  least  its  adnexa,  in  case  the  patient's 
life  is  rendered  intolerable  by  obstinate  atresia.^ 

The  surgery  of  the  perineum  and  vagina  is  a  subject  of  interest  to 
gjTiecologists.  .  The  variety  and  complicacy  of  the  lesions  are  far  greater 
than  I  have  thought  best  to  describe  in  this  short  chapter,  but  the  gen- 
eral surgeon  will  scarcely  find  time  to  concern  himself  with  such  consid- 
erations. 

1  See  interesting  case  reported  by  Heidenhain,  Monats.  f.  Geb.  u.  Gyn.,  March, 
1904,  p.  445.  Incision  of  the  obstruction  was  followed  by  a  long  train  of  symptoms, 
eventuating  in  menstrual  retention,  pelvic  abscess,  fecal  fistula,  and  death. 


PART  III 

GENITO-URINARY  ORGANS 


CHAPTER   XIII 

KIDNEY  AND  URETERS 

Mr.  Thomas  Bryant,  writing  in  1884,  said  of  renal  surgery  that 
"  this  branch  of  surger}'  has  reached  a  definite  position,  and  if  it  rises  in 
value  as  it  has  risen  in  interest,  a  wide  surgical  field  has  indeed  been 
opened.  It  is  to  Simon,  of  Heidelberg,  that  we  are  indebted  for  its  birth, 
in  that  he  in  18G9  first  designedly  removed  a  kidney  with  success."  The 
last  cjuarter  of  a  century  has  shown  the  correctness  of  Bryant's  foresight, 
for  renal  surgery  has  come  to  occupy  a  leading  position  among  us,  and 
eminent  men  have  devoted  themselves  to  genito-urinaiy  diseases  alone. 

Surger}^  of  the  kidney  is  of  profound  interest  and  importance  because 
it  deals  with  a  vital  organ;  because  it  approaches  intelhgently  and 
boldly  lesions  formerly  treated  blindly  and  timidly;  and  because  it 
affords  relief  or  permanent  cure  for  diseases  once  agonizing,  lingering, 
and  fatal.  The  subject  is  broad  and  intricate.  Let  us  endeavor  to 
formulate  and  grasp  its  outlines  in  a  few  pages. 

In  general  terms  siirgery  of  the  kidne}'  embraces  a  consideration  of 
that  organ's — (1)  Malformations  and  malpositions;  (2)  its  injuries  by 
violence;  (3)  its  inflammations,  including  calculus  formation;  (4)  its 
tumors.  The  reader  must  recognize  always  that  for  surgical  purposes 
the  ureter  may  be  regarded  as  a  part  of  the  renal  apparatus,  because 
injuries  and  diseases  of  the  ureter  are  intimately  associated  with  renal 
disease.  Functionally  and  anatomicalh'  the  ureter  is  as  much  a  part 
of  the  kidney  as  are  the  renal  artery  and  vein.  One  might  carry  the 
analogy  further  and  point  out  how  the  more  distant  parts  of  the  urinary 
apparatus,  the  bladder  and  urethra,  often  are  intimately  concerned 
with  renal  disease.  But  such  a  thesis  would  carry  us  too  far  afield, 
though  the  association  must  be  recalled  from  time  to  time. 

ANATOMIC  RELATIONS 

The  gross  anatomic  relations  of  the  kidney  must  concern  us  here  for 
a  moment,  but  one  must  assume  that  the  reader  is  familiar  with  the 
minute  anatomy  of  the  kidney  itself.  The  surgeon  may  most  quickly 
and  directly  expose  the  kidne}'  by  opening  through  the  posterior  lumbar 

358 


ANATOMIC   RELATIONS  359 

triangle^  which  is  formed  by  the  last  rib  and  the  tendinous  aponeuroses 
of  the  oblique  muscles.  Through  a  3-inch  oblique  incision  the  operator 
enters  almost  at  once  upon  the  fatty  capsule  of  the  kidney,  no  important 
structures  being  cut,  but  the  aponeuroses  being  drawn  aside  or  split. 
The  kidney,  thus  exposed,  is  covered  by  3  capsules — the  tunica 
propria,  the  capsula  adiposa,  and  the  fascia  renalis.  None  of  these 
structures  has  any  important  part  in  holding  the  kidney  in  place, 
however.  The  kidney  is  not  a  fixed  organ,  but  moves  slightly  up  and 
down  with  the  diaphragm  in  respiration.  Such  support  as  the  kidney 
has  is  given  by  the  renal  vessels  and  ureter,  the  fossa  in  which  it  lies, 
and  through  the  pressure  of  the  peritoneum  and  superimposed  organs. 
The  two  kidneys  lie  on  either  side  of  the  spinal  column  and  extend  from 
the  upper  border  of  the  twelfth  dorsal  vertebra  to  the  lower  border  of 
the  second  lumbar.     The  twelfth  rib  crosses  them  at  about  their  middle, 


Fig.  226. — Kelly's  method  of  approaching  the  kidney  and  ureter  without  opening  the 

peritoneum  (Kelly). 

but  the  left  kidney  lies  about  a  finger's  breadth  higher  than  does  the 
right,  which  receives  the  constant  impact  of  the  liver.  The  distance 
between  the  upper  pole  of  the  kidney  and  the  pleural  cavity  is  but  a 
fraction  of  an  inch.  Both  kidneys  lie  behind  the  peritoneum.  Among 
the  most  important  relations  of  the  right  kidney  are  the  liver  above, 
the  hepatic  flexure  of  the  colon,  which  lies  upon  its  lower  third,  and  the 
duodenum,  which  is  adherent  close  to  its  inner  edge.  One  recognizes 
the  significance  of  these  relations  when  a  paranephritic  abscess  opens 
into  the  bowel.  The  left  kidney  in  its  upper  third  lies  close  to  the  stom- 
ach, from  which  it  is  separated  by  the  splenic  artery;  its  middle  third 
lies  against  the  pancreas,  while  its  external  border  rests  against  the 
spleen  and  the  descending  colon.     Those  interesting  and  significant 

1  H.  A.  Kelly,  Lancet,  June  17,  1905. 


360  GEXITO-URIXARY    ORGANS 

organs,  the  suprarenal  glands,  arc  loosely  connected  with  each  kidney, 
to  the  right  of  the  kidney's  upper  pole. 

The  ureter  begins  at  the  pelvis  of  the  kiihicy,  and  thioughout 
much  of  its  length  follows  a  fairly  straight  course  to  the  base  of  the 
bladder.  It  is  somewhat  narrowed  at  its  beginning,  and  at  the  point 
where  it  passes  over  the  brim  of  the  pelvis.  Stricture  may  occur  at 
these  places.  The  ureter  is  behind  the  peritoneum,  and  in  the  greater 
portion  of  its  course  may  easily  be  exposed  through  an  incision  extending 
from  the  twelfth  rib  diagonally  past  the  anterior-superior  spine  of  the 
ilium.  Through  this  incision  the  peritoneum  is  reached  and  pushed  aside, 
when  the  retroperitoneal  space  is  disclosed.  The  ureter  is  found  lying 
upon  the  psoas  muscle.  At  the  brim  of  the  pelvis  the  ureter  turns 
sharply  backward  to  run  along  the  side  of  the  pelvis,  to  a  point  about 
one  inch  in  front  of  the  spine  of  the  ischium ;  then  it  passes  forward  and 
inward  on  the  upper  surface  of  the  levator  ani  muscle  until  it  reaches 
the  base  of  the  bladder.  The  length  of  the  average  adult  ureter  is 
12  inches. 

In  this  brief  essay  there  is  not  space  to  consider  the  various  congenital 
malformations  and  abnormalities  of  the  kidneys.  The  operating  sur- 
geon must  not  forget,  however,  when  he  proposes  extirpation  of  a  kidney, 
that  there  may  be  but  one  kidney.  A  common  abnormality  is  horseshoe 
kidney,  which  should  not  properly  be  regai'ded  as  a  single  kidney,  but 
as  two  kidneys  connected  by  an  isthmus  of  renal  tissue.  The  double 
organ  thus  formed  is  usually  displaced  downward,  and  is  situated  in 
front  of  the  spinal  column.  Double  ureter  from  either  kidney  some- 
times is  found. 

We  need  not  consider  further  the  question  of  vwvaUe  kidney  and  the 
problems  which  it  suggests.  I  have  already  discussed  these  matters  in 
the  first  portion  of  Chapter  IX. 

DIAGNOSIS   IN  RENAL  DISEASE 

Let  us  now  briefly  turn  to  the  more  common  methods  of  diagnosis 
in  renal  disease.  Such  diagnosis  may  be  simple  or  may  present  some 
of  the  greatest  difficulties  in  the  w^hole  field  of  surgery.  The  history 
of  the  case  may  or  may  not  be  important.  The  patient  may  tell  of  pain, 
paroxysmal  or  constant,  suggesting  calculus  or  tuberculosis.  He  may 
describe  a  long  train  of  dyspeptic  symptoms  suggesting  movable  kidney. 
He  may  have  noticed  a  pronounced  tumor.  He  may  have  been  troubled 
with  the  intermittent  passage  of  great  quantities  of  urine.  He  may 
have  passed  blood.  He  may  tell  a  story  of  gradual  and  increasing 
debility,  suggesting  cancer  or  tuberculosis.  He  may  tell  of  such  asso- 
ciated symptoms  as  exquisite  pain  in  one  renal  region,  with  nausea, 
vomiting,  headache,  wasting,  and  general  prostration.  The  fact  is 
that  almost  all  lesions  of  the  kidneys  may  be  characterized  by  similar 
symptoms,  and  so  it  rarely  happens  that  a  positive  diagnosis  can  be 
founded  upon  the  patient's  story.  Furthermore,  a  trifling  lesion  may 
give  rise  to  distressing  symptoms,  while,   on  the  other  hand,  grave 


DIAGNOSIS    IN    RENAL   DISEASE  361 

kidney  disease  may  run  its  full  course  without  any  pronounced  sugges- 
tion of  kidney  disorder.  Palpation  of  the  kidney  is  sometimes  easy, 
or  may  be  extremely  difficult,  depending  on  the  size  of  the  kidney  and 
the  thickness  of  the  patient's  abdominal  walls.  Examine  the  patient 
as  he  lies  on  his  back,  again  while  he  is  in  a  half-reclining  position,  on 
his  side,  and  in  the  hands-and-knees  position.  Movable  kidneys  and 
enlarged  kidneys  may  thus  be  made  to  appear  and  disappear.  Palpate 
bimanually  as  you  stand  facing  the  patient ;  pass  the  fingers  of  one  hand 
up  his  back  and  beneath  the  twelfth  rib ;  press  deeply  with  the  other  hand 
below  the  costal  arch.     In  the  case  of  thin  patients  the  opposing  hands 


Fig.  227. — Method  of  palpating  the  kidney. 

may  thus  be  brought  close  together,  and  sometimes  a  normal  kidney 
may  be  felt.  Palpation  of  the  abdomen  rarely  reveals  any  disorder  of 
the  ureters,  though  extreme  ureteral  dilatation,  or  a  large  calculus 
impacted  in  the  ureter,  sometimes  may  be  felt.  Sometimes,  again, 
beware  lest  you  confound  with  renal  tumor  a  tumor  of  the  intestine, 
of  the  liver,  or  of  the  spleen.  The  distinction  may  be  made  by  distend- 
ing the  colon  with  air,  bearing  in  mind  that  that  viscus  lies  in  front 
of  either  kidney.  Disease  of  the  ureter— tuberculosis,  dilatation,  and 
calculus — sometimes  may  be  ascertained  by  palpation  through  the 
rectum  or  vagina.  A^ialysis  of  the  urine  is  of  service.  The  exam- 
iner looks  especially  for  blood,  for  crystals,  for  tubercle  bacilli,  and 


362 


GENITO-URINARY   ORGANS 


for  shreds  of  tissue  even.  He  should  differentiate  between  hematuria 
and  hemoglobinuria.  He  must  try  to  distinguish  whether  the  blood 
comes  from  the  bladder  or  the  kidney,  and  he  must  look  for  pus  also 
and  try  to  ascertain  its  origin.  Such  are  the  older  and  more  commonly 
recognized   methods  of  investigating  renal  disease.     We  may  regard 


Fig.  228. — Examination  of  the  bladder  in  the  dorsal  position,  with  elevated  pelvis 

(Kelly). 


such  methods  as  preliminary  steps,  but,  not  satisfied  with  results  thus 
obtained,  we  must  then  proceed  with  examination  by  the  cystoscope, 
and  may  employ  sometimes  cryoscdpy  and  the  phloridzin  test. 

The  cystoscope  within  recent  years  has  placed  renal  surgery  on  a 
new  basis.     This  instmment  enables  us  to  make  a  visual  inspection  of 


Fig.  229. — Instrument  for  measuring  the  distance  between  the  internal  orifice  of  the 
urethra  and  various  portions  of  the  vesical  walls  (Kelly). 

the  bladder,  to  watch  the  vesical  openings  of  the  ureters,  and  to  cathe- 
terize  the  ureters,  in  order  to  segregate  the  urine  fi'om  the  individual 
kidneys.  Inspection  of  the  female  bladder  is  easy  compared  with  inspec- 
tion of  the  male  bladder.  More  than  ten  years  ago  Kelly  popularized 
cystoscopy  of  the  female  bladder,  and  his  method  is  still  that  commonly 


DIAGNOSIS   IN   RENAL   DISEASE 


363 


employed.  With  the  patient  in  the  exaggerated  knee-chest  or  the  Tren- 
delenburg position,  the  female  bbuUler  may  be  inspected  directly  through 
an  open  tube,  the  ureters  may  be  observed,  and  the  ureteral  catheter 
may  be  passed.  The  illustration  shows  Kelly's  method,  but  personal 
instruction  in  the  clinic  is  necessary  if  one  would  learn  and  apply  the 
technic.  A  more  complicated  instrument  is  required  for  inspection 
of  the  male  bladder,  but  all  the  instruments  used  are  adaptations  of  the 
well-known  Xitze  apparatus.  I  need  not  discuss  the  great  variety  of 
ingenious  inventions  and  modifications  of  the  cystoscope  further  than 
to  mention  the  names  of  such  investigators  as  Hill,  Fenwick,  Thompson, 
Boisseau,  du  Rocher,  Casper,  Akbarran,  and  Tilden  Brown.  Brown 
has  devised  one  of   the  simplest  of    catheterizing  cystoscopes.      Such 


Fig.  230. — Speculum  with  oblique  end  for  collecting  the  urine  directly  from  the 

ureter  (Kelly-Noble). 

instruments  generally  can  be  used  with  the  aid  of  local  anesthesia 
only.  First  one  explores  thoroughly  the  bladder  in  order  to  deter- 
mine the  presence  of  stone,  of  tumor,  of  ulceration,  or  of  other 
lesions  which  may  complicate  the  diagnosis.  Then  one  inspects  the 
ureteral  openings,  noting  any  swelling,  pouting,  pus  or  blood  from 
the  ureters.  By  watching  the  contractions  of  the  ureteral  openings, 
the  spurtings  of  urine  and  the  intervals  between  them,  one  gains  some 
information  about  the  activity  of  the  kidneys.  B}^  giving  certain  drugs 
which  color  the  urine  two  purposes  are  answered.  Methylene-blue  and 
indigo  carmin  make  the  urinary  whirl  more  visible,  and  in  the  case  of 
normal  kidneys  the  colored  stream  should  appear  in  the  bladder  in  from 
fifteen  to  thirty  minutes  after  the  drug  has  been  taken.  A  crippled 
kidney  passes  on  the  colored  stream  after  a  longer  interval.     Having 


364  GENITO-URINARY   ORGANS 

made  these  observations,  the  surgeon  catheterizes  the  ureters  according 
to  the  following  principles :  As  soon  as  the  mouth  of  the  ureter  is  found, 
the  cystoscope  should  he  so  directed  that  the  ureter  occupies  the  lower 
margin  of  the  inner  field  of  vision.  The  ureteral  catheter  is  then  pushed 
slightly  forward  so  that  the  direction  of  its  point  may  be  observed. 
Then,  by  a  little  manipulation  of  the  instrument,  the  surgeon  can  direct 
the  point  of  the  catheter  into  the  ureter.  Some  surgeons  have  objected 
to  ureteral  catheterization  on  the  ground  that  the  ureter  and  kidney 
may  thus  be  directly  infected  from  the  bladder.  In  order  to  minimize 
this  danger  one  should  irrigate  thoroughly,  with  4  per  cent,  boric-acid 
solution,  the  bladder  before  passing  the  ureteral  catheter. 

As  the  collection  of  the  urine  from  the  individual  kidneys  is  an  im- 
portant object  of  these  investigations,  and  as  some  danger  undoubtedly 
inheres  in  the  use  of  the  ureteral  catheter,  surgeons  have  sought 
other  means  of  segregating  the  urine.  M.  L.  Harris  has  devised  a 
popular  instrument  which  is  illustrated  by  the  cut.     The  principle  of 


Fig.  231. — Harris's  instrument  fitted  for  use. 

Harris's  instrument  is  that  it  throws  the  base  of  the  bladder  into  two 
small  distinct  pockets  at  the  bottom  of  which  lie  the  individual  ureteral 
openings.  When  these  pockets  are  formed,  the  urines  from  the  two 
kidneys  separately  collect  in  them.  Then  from  each  pocket  these  segre- 
gated urines  are  drawn  off  by  separate  catheters  and  a  suction  apparatus. 
Luys  and  Cathehn  also  have  devised  segregating  instruments,  but  Har- 
ris's is  the  most  popular  with  us. 

Cryoscopy  is  a  method  of  investigation  which  is  growing  in  favor 
and  is  giving  increasingly  satisfactory  results  in  the  hands  of  its  more 
skilled  advocates.  The  principle  of  cryoscopy  is  this:  we  have  ascer- 
tained that  normal  urine  freezes  at  a  point  between  — 1.20°  C.  and 
— 2.30°  C,  while  the  freezing-point  of  blood  in  normal  individuals 
is  found  practically  constant  at  — 0.56°  C.  If  the  kidney  is  doing  less 
than  its  proper  work  and  excreting  an  attenuated  urine  approximating 
the  characteristics  of  water,  the  freezing-point  of  such  urine  will  rise 
toward  zero.     If  the  freezing-point  of  blood  falls  below  —0.56°  C,  one 


DIAGNOSIS   IN   RENAL   DISEASE 


365 


must  conclude  that  the  blood  is  carrying  abnormal  constituents.  If  the 
freezing-point  of  a  given  specimen  of  blood  sinks  as  low  as  — 0.60°  C, 
we  conclude  that  operation  on 
one  of  the  kidneys  would  be  un- 
safe, since  with  such  blood  as 
this  it  is  improbable  that  proper 
urinary  secretion  would  con- 
tinue should  a  serious  operation 
be  performed.  It  is  obvious 
that  there  are  elements  of 
error  in  the  use  of  cryoscopy 
unless  the  method  be  supervised 
by  a  person  skilled  in  the  tech- 
nic.  Moreover,  it  is  reasonably 
doubtful  whether  the  old  recog- 
nized methods  of  urinalysis  may 
not  give  us  data  of  greater 
value.  The  normal  percentage 
of  urea  should  be  2.02  per  cent. ; 
of  uric  acid,  O.O-l  per  cent. ;  and 
the  ratio  between  uric  acid  and 
urea  should  be  about  as  1  is  to 
50.  When  employing  cryos- 
copy, the  estimation  of  the 
freezing-point  of  the  urine  may 
lead  into  error  the  unwary,  if 
he  does  not  take  into  considera- 
tion the  total  amounts  of  urea 
and  uric  acid  excreted  in  the 
twenty-four  hours,  but  carried 
in  a  urine  of  low  specific  gravity. 
In  general  terms,  however,  we 
are  justified  in  feeling  that 
a  thorough  urinalysis,  supple- 
mented by  cryoscopy,  and  es- 
pecially by  an  estimate  of  the 
blood's  freezing-point,  will  en- 
able us  to  determine  with  safety 
the  question  as  to  whether  or 
not  we  shall  operate  in  a  given 
case. 

I  have  spoken  of  the  methy- 
lene-hlue  test.  This  is  com- 
monlj^  known  as  the  phloridzin 
test.  The  close  is  given  h3'po- 
dermically — phloridzin,  0.05 
gm.  in  1   cc.  of  sterile  water. 


Fig.  232. — Apparatus  for  cryoscopy  (Fowler). 
The   characteristic  blue  color  should 


appear  in  the  urine  within  half  an  hour  if  the  kidneys  be  normal.     Un- 


366  GEXlTO-UlU.\AI{Y    OKGAXS 

fortunately,  this  test  is  not  always  reliable,  as  the  blue  urine  of  damaged 
kidneys  sometimes  appears  within  the  half-hour. 

Certain  recognized  symptoms  bearing  upon  the  diagnosis  are  looked 
for  in  all  kidney  diseases:  hemorrhage,  pain,  frequency  of  micturition, 
pain  on  micturition,  and  a  peculiar  character  of  the  stream.  I  shall 
not  discuss  these  symptoms  in  detail  here,  but  shall  deal  with  them 
appropriately  when  describing  special  diseases.' 

INJURIES   OF  THE  KIDNEY 

Injuries  of  the  kidneys  should  be  divided  into  two  distinct  classes — 
injuries  from  blows  and  injuries  from  penetrating  wounds.  By  blows 
the  kidne}^  is  crushed  or  ruptured  and  the  vessels  and  ureter  may  be  torn, 
while  penetrating  wounds  give  rise  to  a  single  lesion. 

Ruptured  Kidney. — A  few  years  ago,  at  the  Massachusetts  General 
Hospital,  I  was  asked  to  see  a  young  man  who  had  been  brought  there 
in  a  state  of  prostration.  His  story  was  that  while  carrjang  on  his  head 
a  heavy  mattress,  a  companion  had  jumped  upon  it  in  sport,  and  that 
he  had  doubled  up  and  fallen,  with  the  sensation  of  acute  pain  in  his 
right  loin.  He  became  faint  and  helpless,  and  in  that  condition  was 
carried  to  the  hospital.  The  house  surgeon  discovered  an  area  of 
tenderness  in  the  region  of  the  right  kidney,  and  drew  bloody  urine 
with  the  catheter  from  the  bladder.  We  made  a  diagnosis  of  ruptured 
kidney,  but  as  the  patient  rallied  somewhat,  I  decided  to  await  develop- 
ments. For  three  days  he  continued  in  a  depressed  condition,  with  a 
constant  passage  of  bloody  urine,  and  at  the  end  of  that  time  he  began 
to  develop  a  fever  and  other  progressively  alarming  symptoms.  There- 
upon I  cut  down  upon  the  kidney  and  found  it  extensively  lacerated, 
with  the  lower  third  almost  completely  separated  from  the  rest  of  the 
organ.  Removal  of  the  kidney  was  followed  by  the  patient's  recovery. 
I  have  related  this  case  in  order  to  show  the  difficulty  of  exact  diag- 
nosis.    The  extent  of  damage  to   the   kidney  cannot  be  ascertained 

^  Da  Costa  quotes  Sir  Henry  Thompson's  diagnostic  questions  as  follows: 

"  1.  Have  you  any,  and  if  so  what,  frequency  in  passing  water?  Is  frequency 
more  manifest  during  the  night  or  the  day?  Is  frequency  more  manifest  during 
motion  or  rest?     Does  any  other  circumstance  affect  it? 

"  2.  Is  there  pain  on  passing  urine,  and  if  so,  before,  during,  or  after  the  act? 
What  is  its  character — acute,  smarting,  dull,  transitory,  or  continuous?  What  is 
its  seat?  Is  it  felt  at  other  times,  and  is  it  produced  or  intensified  by  sudden  move- 
ments? 

"  3.  What  is  the  character  of  the  stream?  Is  it  small  or  large;  twisted  or  irreg- 
ular; strong  or  weak;  continuous,  remitting,  or  intermitting?  Does  it  come  by  the 
meatus,  or  partly  or  entirely  through  fistulfp? 

"  4.  Is  the  character  of  the  urine  altered?  Wliat  is  its  appearance,  color, 
odor,  reaction,  and  specific  gravity?  Is  it  clear  or  turbid,  and,  if  turbid,  is  it  so  at 
the  time  of  passing?  Does  it  vary  in  quantity?  Are  the  normal  constituents 
increased  or  diminished?  Does  it  contain  abnormal  elements,  as  albumin  or  sugar? 
What  morganic  deposits  are  found?     What  organic  materials  are  met  with? 

"  5.  Has  the  urine  ever  contained  blood?  If  so,  was  the  color  brown  or  bright 
red?  Were  the  blood  and  urine  thoroughly  mixed:  was  the  blood  passed  at  the  end 
or  the  beginning  of  micturition:  or  did  it  come  only  with  the  last  drops  of  urine;  or 
was  it  passed  independently  of  micturition? 

"  6.  Inquire  as  to  pain  in  the  back,  loins,  and  hips,  permanent  or  transitory, 
and  for  the  occurrence  of  severe  paroxysms  of  pain  in  these  regions." 


INJURIES    OF    THE    KIDNEY  367 

before  operation.  Extreme  laceration  may  be  associated  with  appar- 
ently trifling  symptoms,  while  a  presumably  slight  laceration  may  be 
followed  by  alarming  symptoms. 

Kidneys  are  ruptured  by  the  most  diverse  forces — by  blows,  kicks, 
crushes,  and  by  such  a  doubling-up  of  the  body  as  I  have  described. 
A  stellate  rupture,  transverse  and  extending  into  the  renal  pelvis,  com- 
monly occurs.  Then  there  follow  hemorrhage,  a  more  or  less  profuse 
soaking  of  blood  into  the  pararenal  tissues,  and  the  passage  of  blood 
through  the  ureter  into  the  bladder.  Sometimes  the  ureter  is  damaged 
or  obstructed,  with  a  resulting  escape  of  urine  into  the  tissues  of  the 
back;  or  a  hydronephrosis  may  develop,  through  distention  of  the  renal 
pelvis  with  urine  that  cannot  find  its  way  to  the  bladder.  Rarely, 
both  kidneys  are  damaged  simultaneously. 

The  symptoms  of  ruptured  kidney  are  often  more  alarming  than  one 
would  expect,  and  the  shock  and  collapse  are  profound.  The  nervous 
mechanism  of  the  kidney,  through  its  associations,  frequently  produces 
unexpected  reflex  symptoms,  such  as  vomiting,  intestinal  paralyses, 
and  dyspnea.  In  addition  to  the  profound  shock  the  patient  experiences 
extreme  pain  in  the  renal  region,  the  pain  sometimes  radiating  along 
the  course  of  the  ureter;  and  there  may  be  retraction  of  the  scrotum. 
Again,  the  pain  may  be  slight,  increasing  perhaps  with  the  progress  of 
the  hemorrhage.  The  passage  of  clots  through  the  ureter  causes  in- 
tense pain.  The  most  conspicuous  diagnostic  sign  of  ruptured  kidney 
is  bloody  urine.  The  urine  may  be  continually  encumbered  with  clots 
and  blood,  showing  that  the  canal  of  the  ureter  is  open,  or  there  may  be 
but  slight  transient  hematuria,  suggesting  rupture  of  the  ureter.  Such 
are  the  early  symptoms.  If  the  case  progress  without  operation,  later 
symptoms  may  develop,  due  to  infection  of  the  blood  and  urine  poured 
out  into  the  loin.  So  there  may  result  pararenal  suppuration,  gangrene, 
or  involvement  of  the  peritoneum  in  peritonitis,  with  distention  and 
the  other  acute  abdominal  symptoms  familiar  to  us  as  associated  with 
peritonitis. 

The  outlook  in  the  case  of  ruptured  kidney  is  always  grave,  and  statis- 
tics show  a  mortality  of  about  47  per  cent.  Such  statistics  do  not 
take  into  account  modern  methods  of  treatment,  but,  at  the  best,  the 
surgeon  faces  a  formidable  injury. 

Treatment. — The  story  of  the  young  man  crushed  under  the  mattress 
suggests  the  difficulty  of  laying  down  precise  rules  for  treatment.  In 
general  terms,  one  should  not  operate  hastily,  because  we  know  that 
many  of  these  patients  recover  spontaneously.  If  an  operation  be  not 
our  resort,  the  treatment  is  symptomatic;  absolute  rest,  the  cautious 
employment  of  morphin  to  control  pain  and  reduce  shock,  an  abundant 
milk  diet  with  plenty  of  water  to  drink,  and  keeping  the  bladder  drained 
and  relieved  of  clots,  by  washing  ovit,  if  necessary,  with  the  Bigelow 
evacuator.  On  the  other  hand,  if  there  is  strong  reason  to  suspect  that 
the  ureter  is  ruptured,  and  if  hemorrhage  persists  or  increases  for  a  day 
or  two,  or  even  less,  the  surgeon  must  cut  down  upon  the  kidney  and 
attempt  to  remedy  the  damage.     I  have  found  the  most  satisfactory 


368  GENITO-UIUXAHY    ORGANS 

method  of  approaching  the  kidney  in  these  cases  to  be  through  an 
oblique  incision  extending  from  the  twelfth  rib  forward  along  the  iliac 
crest.  Thus  the  i)eritoneum  may  be  sought  and  turned  fcjrward  and  a 
free  opening  matle,  extraperitoneal,  rendering  easily  accessible  the  Avhole 
of  the  renal  and  ureteral  region.  A  few  years  ago  we  invariably  removed 
these  damaged  kidneys,  and  nephrectomy  still  is  often  imperative,  but, 
thanks  to  the  work  of  Kiister  and  Keetley,  published  in  1891,  we 
have  learned  to  be  more  conservative.  They  showed  that  many 
ruptured  kidneys  can  be  treated  successful!}'  by  a  packing  of  the  renal 
wound.  In  one  case  I  sewed  with  plain  catgut  sutures  a  gauze  tampon 
tightly  into  such  a  wound  and  checked  the  hemorrhage.  The  gauze 
was  removed  early  on  the  fifth  day.  In  case  of  suturing  the  kidneys 
with  catgut  the  suture  material  is  absorbed  in  twenty-four  hours  or  less, 
so  that  it  retains  the  gauze  for  a  short  time  only,  but  long  enough  to 
control  hemorrhage. 

If  one  sees  a  ca'se  several  days  after  the  accident,  when  secondary 
symptoms  have  developed,  operation  may  be  impossible  on  account  of 
the  wretched  condition  of  the  patient;  or  an  elaborate  operation  may  be 
undertaken  if  the  patient  has  the  strength  for  it.  Transfusion  of  blood 
may  bring  the  patient  into  a  condition  suitable  for  operation.  The 
kidney  should  be  approached  through  the  incision  I  have  already  des- 
cribed; blood-clots  and  the  products  of  infection  should  be  removed; 
and  the  wound  should  be  drained  extraperitoneally.  If  the  peritoneum 
has  been  opened  and  infected,  a  drain  should  be  inserted  at  the  point 
of  its  opening,  but  no  further  treatment  of  the  peritoneal  cavit}'  is 
advisable.  The  after-treatment  of  these  cases  embraces  two  considera- 
tions, depending  upon  whether  or  not  the  peritoneum  has  been  infected. 
If  we  are  dealing  with  an  extraperitoneal  wound,  we  should  treat  it  on 
the  simplest  of  principles — by  local  drainage,  cleanliness,  and  general 
supporting  treatment.  If  we  are  dealing  with  a  peritonitis,  we  should 
follow  the  line  of  treatment  I  described  in  Chapter  Mil — Fowler's 
position  and  salt  solution  enemata.^ 

Thus  we  have  seen  that  subcutaneous  rupture  of  a  kidne}-  is  a  con- 
dition of  extreme  gravity.  Generally,  these  ruptures  are  uncom- 
plicated, though  in  some  extensive  crushing  accidents  the  damage  to  the 
kidney  niay  be  but  part  of  a  general  visceral  disorganization,  with  bruis- 
ing or  rupture  of  intestines,  liver,  stomach,  and  other  organs.  As  a 
rule,  however,  ruptures  of  the  kidney  are  not  so  complicated. 

Quite  otherwise  is  the  fact  with  penetrating  wounds  of  the  kid- 
ney— stab  wounds,  incised  wounds,  and,  most  connnon  of  all.  gunshot 
wounds.  The  reader  will  see  at  once  that  these  penetrating  wounds, 
especially  gunshot  wounds,  may  readily  involve  other  organs.  A  bullet 
does  not  stop  at  the  kidney,  but  may  penetrate  the  abdominal  cavity 
and  injure  the  intestines,  the  Hver,  the  stomach,  the  spleen,  and  the 
spinal  column  even.     Such  injured  organs  must  be  treated  on  appro- 

^  The  most  extensive  and  satisfacton'  description  of  these  kidney  injuries  which 
I  have  seen  was  published  by  Francis  S.  Watson  in  the  Boston  Med.  and  iSurg.  Jour., 
July  9,  1903. 


STONE    IN    THK    KIDNEY  369 

priate  priiu'i])lcs,  but  wc  are  concerned  here  with  the  kidney  especially, 
and  in  g(>neral  terms  nuich  the  same  situation  arises  as  we  saw  in  the 
case  of  ruptured  kidney.  There  are  the  primary  shock,  pain,  and  hemor- 
rhage, varying  in  extent,  but  generally  less  conspicuous  than  with  rup- 
tured kidney.  If  the  penetrating  wound  be  extensive,  the  kidney  may 
prolapse  through  it.  The  ureter  is  rarely  injured,  but  the  danger  of 
infection  is  great.  The  symptoms  are  quite  similar  to  those  of  ruptured 
kidney,  and  the  treatment  is  analogous.  It  may  seem  wise  at  first  simply 
to  clean  the  wound  and  await  developments.  Later,  if  pain,  hemor- 
rhage, and  collapse  continue,  and  if  sepsis  supervene,  one  should  cut 
down  upon  the  organ  and  treat  it  by  suture,  tampon,  or  excision,  as 
may  seem  wise  at  the  time. 

Open  wounds  of  the  kidney  are  rare  as  compared  with  subcutaneous 
wounds. 

STONE  IN  THE  KIDNEY 

Stone  in  the  kidney  (nephrolithiasis;  calculus),  more  than  any 
other  form  of  renal  disease  probably,  concerns  the  surgeon.  In  study- 
ing the  formation  of  gall-stones  (Chapter  V)  we  saw  that  they  are  de- 
pendent upon  a  primary  infection — first,  the  infection;  then,  the  in- 
flammation; then,  the  formation  of  biliary  concretions.  The  formation 
of  renal  concretions  appears  to  follow  a  reverse  order,  so  far  as  our  studies 
have  instructed  us.  Urinary  concretions  form  commonly  in  the  kidneys 
and  in  the  urinary  bladder,  though  they  may  be  found  anywhere  in 
the  urinary  tract,  but  their  deposition  seems  to  be  dependent  upon  a 
condition  of  the  excreted  urine  itself,  rather  than  upon  any  inflam- 
matory condition  of  the  renal  or  bladder  mucosa.  There  are  exceptions 
to  this  rule,  as  is  seen  in  the  formation  of  urinary  concretions  secondary 
to  obstruction  and  inflammation  somewhere  in  the  urinary  tract.  The 
right  kidney,  like  other  structures  on  the  right  side  of  the  abdomen,  is 
the  more  frequently  the  seat  of  stone,  though  rarely  both  kidneys  may 
bear  calculi.  As  a  rule,  however,  nephrolithiasis  seems  to  be  a  part  of  a 
general  condition.  The  older  writers  included  it  under  the  term  "  gouty 
diathesis."  All  the  old  writers  talk  of  stone,  and  from  the  beginnings 
of  surgery  the  treatment  of  stone  has  exercised  general  practitioners 
.and  specialists.  For  a  deposit  of  these  concretions  an  excess  of  certain 
of  the  solid  constituents  of  the  urine  seems  to  be  necessary.  So  long 
ago  as  1776  Scheele  discovered  that  uric  acid  was  a  normal  constitu- 
ent of  the  urine,  and  that  many  calculi  were  made  up  of  uric-acid 
crystals.  Since  then  we  have  learned  that  other  salts  may  enter  into 
the  formation  of  stones — calcium  carbonate,  calcium  phosphate,  calcium 
oxalate,  and  the  corresponding  salts  of  magnesium  and  ammonium; 
more  rarely  cystin  and  xanthin,  and  very  exceptionally  indigo.  As  a 
rule,  the  calculi  contain  a  mixture  of  these  substances,  especially  of 
uric  acid,  but  as  one  or  the  other  predominates,  they  are  known  as  uric 
acid,  oxalate,  or  phosphatic  calculi,  etc.  The  extremely  finely  divided 
deposits  found  in  the  kidney  substances  of  infants  are  knoT\n  as  infarcts, 
and  are  found  in  the  renal  parenchyma;  but  calculi  of  any  appreciable 

24 


370  GENITO-URINARY    ORGANS 

size  are  deposited  in  the  larger  spaces,  in  that  portion  of  the  urinary 
apparatus  which,  beginning  with  the  papilla>,  inckides  the  renal  calices, 
the  pelvis  of  the  kidney,  the  ureter,  and  the  bladder.  Renal  calculi 
are  found  in  persons  of  all  ages,  though  such  calculi  are  not  connnon 
before  puberty,  and  males  are  affected  more  commonly  than  are  females. 
Not  only  are  stones  found  independently  in  the  passages,  but  they  are 
frequently  seen  associated  with  such  crippling  diseases  as  tuberculosis, 
tumors,  and  any  lesion  which  causes  obstruction  to  proper  urinary 
drainage.  The  stones  vary  in  size  from  microscopic  crystals  to  masses 
as  large  as  a  pullet's  egg  or  larger.  In  the  order  of  freciuency  one  finds 
uric-acid  calculi,  oxalate  calculi,  phosphatic  calculi,  calcium  carbonate 
calculi,  and  cystin  calculi.  The  last  two  are  rare,  and  rarer  still  are  the 
xanthin  and  indigo  calculi. 

The  symptoms  of  urinary  calculi  are  obscure  and  variable.  I  have 
many  times  suspected  calculi  when  they  did  not  exist,  and  in  comn;on 
with  all  surgeons  I  have  cut  down  upon  the  kidney  and  ureter  only  to 
find  that  they  were  free  from  stones.  Diverse  diseases  simulate  renal 
calculus — appendicitis,  biliary  calculus,  floating  kidnej-,  renal  tuVjer- 
culosis,  renal  tumor,  spinal  caries,  sacro-iliac  disease,  and  other  more 
rare  ailments.  There  are  four  cardinal  symptoms  of  renal  calculus: 
(1)  Lumbar  pain;  (2)  hematuria;  (3)  anuria;  (4)  pain  on  micturition. 
One  or  all  of  these  symptoms  may  be  absent.  An  aseptic  calculus, 
which  lies  quietly  within  the  renal  parenchyma  or  even  in  the  renal 
pelvis,  may  cause  no  pain ;  but  if  infected  and  motile,  it  may  cause  ex- 
cruciating pain,  especially  in  its  attempts  to  pass  out  of  the  pelvis  into 
the  ureter.  There  is  a  characteristic  pain  of  renal  calculus:  pain 
beginning  in  the  lumbar  region  and  radiating  toward  the  scrotum, 
extending  even  to  the  thighs,  the. buttocks,  and  the  abdominal  organs. 
The  pain  may  be  sudden  and  acute,  or  it  may  be  of  gradual  onset  and 
long  continued.  The  agony  of  this  pain  will  break  down  the  sternest 
philosophy.  The  strong  man  trembles,  sweats,  groans,  and  collapses. 
There  may  be  nausea  and  vomiting ;  there  may  be  intense  vesical  tenes- 
mus, with  the  straining  out  of  a  few  bloody  drops.  If  there  be  a  mere 
slight  passage  of  gravel  through  the  ureter,  all  these  symptoms  may 
be  present,  but  in  milder  form ;  and  all  these  symptoms  may  not  be 
due  to  the  passage  of  a  renal  calculus.  Renal  calculus  is  a  common 
cause,  but  any  cause  which  produces  an  increased  tension  of  the  renal 
capsule  may  provoke  the  same  symptoms.  Hemorrhage  may  be  micro- 
scopic in  amount,  or  may  be  so  profuse  as  to  endanger  life;  the  amount 
usually  is  small.  Hemorrhage  alone  is  not  pathognomonic.  It  is 
found  under  other  conditions,  such  as  tuberculosis  and  tumor.  In 
the  case  of  calculus,  it  is  part  of  a  symptom-complex.  Anuria  is  usually 
a  grave  symptom.  The  case  is  bad  enough  when  a  calculus  completely 
blocks  one  ureter,  but  it  is  much  more  serious  when,  through  reflex 
irritation,  urine  fails  to  flow  from  either  kidney.  Total  anuria  is  well 
recognized,  but  is  rai-e.  Renal  calculus  may  cause  bladder  irritation, 
with  urgency  and  frequency  of  micturition  and  pain  in  the  urethra  at 
the  close  of  the  act. 


STONE    IN    THE    KIDNP]Y  371 

Such  arc  the  leading  symptoms  of  renal  calculus,  and  on  these 
symptoms  one  attempts  to  found  a  diagnosis.  Pain  and  hemorrhage 
are  of  the  first  consequence.  Sometimes  one  can  feel  an  enlarged  kidney, 
cystic  from  ureteral  obstruction.  Rarely  one  can  feel  a  calculus  in  the 
ureter,  either  b}'  abdominal  palpation  or  by  palpation  through  vagina 
or  rectum.  Some  writers  assert  that  strong  percussion  in  the  loin  pro- 
duces characteristic  pain  when  calculus  is  present  in  the  kidney.  I 
have  not  found  this  to  be  true,  though  any  manipulation  in  that  region 
is  often  resented  by  the  sensitive  kidney.  Intermittent  hydronephrosis 
sometimes  is  present,  due  to  the  alternating  impaction  and  retreat  of 
a  stone  from  the  ureteral  stoma.  Analysis  of  the  urine  sometimes 
is  of  value.  It  is  of  value  in  the  case  of  a  movable  and  infected  cal- 
culus, causing  hemorrhage  and  inflammation.  So  we  expect  to  find 
blood  and  pus.  The  condition  of  the  urine  varies;  tRerefore  numerous 
examinations  should  be  made:  sometimes  there  will  be  found  a  few  casts 
and  crystals  of  varying  character.  The  cystoscope  reveals  alterations 
in  the  flow  of  urine  from  the  ureter  of  the  affected  side — bloody  urine, 
cloudy  urine,  or  an  actual  suppression  of  urine.  The  x-tslj  reveals 
renal  calculus  often,  but  the  density  of  a;-ray  shadow^s  varies  with  the 
nature  of  the  calculus,  A  calculus  of  oxalate  throws  a  strong  shadow, 
easily  demonstrable^  as  a  rule;  but  uric-acid  calculi  or  calculi  com- 
posed of  urates  throw"  such  indistinct  shadows  that  these  shadows  can- 
not always  be  recognized  as  a  basis  for  diagnosis.  One  reason  for  the 
obscurity  of  these  shadows  lies  in  the  fact  that  the  kidney  is  not  an 
immovable  organ.  Phosphatic  calculi  throw  almost  no  shadow.  We  are 
coming  to  see  that  x-ray  investigations  for  urinary  calculi  must  be  in- 
trusted to  the  most  experienced  experts  only.  Finally,  renal  or  ureteral 
calculi  may  be  demonstrated  by  the  wax-tipped  ureteral  catheter. 
H.  A.  Kelly  was  the  first  to  employ  such  a  catheter.  The  smooth  surface 
of  the  wax  is  found  to  be  scratched  by  the  stone  after  the  catheter  has 
explored  the  ureter. 

Thus  we  have  seen  the  difficulties  which  encumber  a  diagnosis  of 
renal  calculus,  and  lend  an  element  of  uncertainty  to  treatment. 

The  treatment  of  renal  calculus  cannot  be  discussed  casually,  yet 
a  satisfactory  discussion  of  treatment  is  a  long  story.  Every  case  has 
its  own  proper  indications  for  treatment,  or  perhaps  its  lack  of  indica- 
tions, since  we  are  often  uncertain  in  our  diagnosis.  Treatment  is 
directed  to  three  ends:  to  remove  calculi,  to  repair  damage  caused  by 
the  calculi,  and  to  provide  against  the  recurrence  of  calculus.  If  a 
calculus  be  present,  operation  must  be  our  resort.^  The  much-vaunted 
solvents  of  stone  are  of  no  value  when  once  the  stone  is  formed,  though 
in  order  to  bring  the  patient  into  good  condition,  systemic  treatment 
is  useful  before  operation,  and  must  be  continued  after  operation:  a 
limited  diet;  little  or  no  meat;  the  consumption  of  cereals,  vegetables, 
and  milk;  abundant  water-drinking,  and  iron  for  a  long  time.^     The 

'  Urinary  sand  may  sometimes  be  removed  by  the  free  use  of  diuretics  and  the 
drinking  of  piperazin  water  or  lycetol  (10  grains  in  water  four  times  daily). 
-  Five  grains  of  Blaud's  pill  before  meals. 


372 


GENITO-URIXAKV    ORGANS 


patient  should  exercise  regularly  between  attacks,  and  strive  In  every 
way  to  ])uild  uj)  his  i)hysical  condition,  especially  re^ulatiii^j;  the  ])o\vels 
by  such  appropriate  laxatives  as  Carlsbad  salts  and  cascara  sagrada. 

Thirty  years  ago  surgeons  were  beginning  to  operate  for  renal  cal- 
culus, and  the  teaching  in  those  days  prescribed  removal  of  the  kidney 
as  the  only  resort.  Experience  has  taught  that  this  is  by  no  means  al- 
ways necessary,  and  we  now  preferably  remove  the  stone,  either  by 
splitting  through  the  parenchyma  of  the  kidney,  or,  better,  by  oi)ening 

the  renal  pelvis  or  ureters.  Schede,  quot- 
ing Israel,  enumerates  5  indications  for 
oi:»eration:  (1)  Calculus  anuria,  either  uni- 
lateral or  bilateral;  (2)  an  acute  su])])ura- 
tive  process  induced  by  calculus;  (3)  ob- 
struction of  a  ureter  by  calculus ;  (4)  severe 
renal  hemorrhage;  (5)  intense  pain  or  con- 
stant, long-continued,  dull  pain.  "Writers 
still  debate  whether  or  not  it  is  proper  to 
operate  at  once  upon  making  the  diagnosis, 
or  to  delay  and  employ  palliative  measures. 
I  suppose  the  answer  to  this  question  must 
always  remain  doubtful,  and  nuist  depend 
somewhat  upon  the  circumstances  and 
temperament  of  the  patient.  On  the  one 
hand,  one  would  hesitate  to  operate,  even 
with  an  assurance  of  finding  stone,  upon 
an  old  person  with  seriously  damaged 
kidne3-s.  On  the  other  hand,  one  wovdd 
operate  at  once  upon  a  vigorous  young 
person  one  of  whose  kidneys  contained 
an  aseptic  calculus.  My  own  habit  is  to 
operate  always  and  early  when  a  reason- 
ably positive  diagnosis  has  been  made, 
provided  the  usual  tests  show  that  one  of 
the  kidneys  is  doing  its  work  properly, 
and  provided  the  patient  is  not  suffering 
from  any  other  serious  organic  lesion. 
The  best  way  to  reach  the  kidney  ^  is  through  the  lateral  oblique 
incision,  which  I  have  already  described  in  this  chapter,  turning  back 
the  peritoneum,  and  giving  a  liberal  exposure  to  the  renal  and  uretei-al 
regions.  The  kidney  is  then  dislocated  and  brought  well  up  into  the 
wound.  It  has  been  suggested  that  if  calculi  are  not  readily  palpated, 
they  may  be  seen  with  the  fluoroscope,  but  I  cannot  regard  this  test  as 
essential,  nor  do  I  recommend  it,  because  absence  of  the  expected  shadow 
does  not  necessarily  mean  absence  of  a  uric-acid  or  phosphatic  stone. 
With  the  kidney  in  hand,  three  methods  of  exploring  it  for  stone  have 
been  in  common  use — needling,  opening  the  pelvis,  and  splitting  the 

^  For  various  methods  of  exposing  tlie  kidney  I  refer  the  reader  to  John  F. 
Binnie's  Manual  of  Operative  Surgerj',  part  iv,  Chapter  I. 


Fig.  233.— A,  A,  "  Brodel's 
white  Hne";  B,  B,  line  of  best 
incision  for  splitting  the  kidney 
(Campbell). 


STONE   IN   THE   KIDNEY  373 

parenchyma  (noplirotoniy).  Needling  has  fallen  into  disuse,  as  it  is 
uncertain.  Surgical  ()})inion  is  divided  on  the  question  of  approach 
through  the  p<'lvis  or  through  the  parenchyma.  Approach  through 
the  pelvis  is  gaining  in  popularity,  and  I  personally  prefer  to  employ  it. 
It  is  extremely  easy:  the  surgeon  seizes  the  kidney  in  his  hand;  incises 
the  pelvis ;  searches  the  pelvis  and  calicos  for  stone ;  and  repairs  the  rent 
with  Lembert  stitches.  The  wound  must  be  drained,  for  it  often  leaks 
urine  for  several  weeks.  A  splitting  of  the  parenchyma  was  and  still 
is  a  popular  method  with  many  surgeons.  At  first  thought  one  might 
suppose  that  it  would  give  rise  to  uncontrollable  hemorrhage,  but  the 
studies  of  Zondek  and  Brodel  have  shown  that  by  splitting  longitudin- 
ally in  a  line  from  0.5  to  0.7  cm.  (0.2  to  0.3  inch)  behind  the  middle  line, 
one  will  avoid  wounding  important  vessels.  The  boundary  line  be- 
tween the  arterial  system  of  the  anterior  and  posterior  portions  of  the 
kidney  is  sharply  distinct.  Split  the  cortex,  then,  and  open  one  of 
the  calices. 

Splitting  the  kidney  substance  results  in  a  considerable  hemorrhage, 
which  is  sometimes  alarming,  but  this  may  readily  be  checked  by  pack- 
ing. Some  surgeons  control  hemorrhage  by  placing  a  temporary  rubber 
ligature  about  the  renal  vessels  and  removing  it  at  the  end  of  the  opera- 
tion. When  one  of  the  calices  has  been  opened,  it  may  be  searched  with 
an  instrument  or  the  finger,  and  through  this  opening  the  exploration 
may  be  continued  into  the  other 
calices  and  the  renal  pelvis.  In 
this  way  an  exhaustive  search 
readily  is  made,  so  that  there  is 
no  excuse  for  overlooking  the 
smallest  calculus.  Thus  the  sur- 
geon may  remove  stones  and  may 
wash  out  and  drain  the  renal 
pelvis.  At  the  end  of  the  opera- 
tion he  had  best  treat  the  kidney 
by  gauze  packing,  securing  it,  if 
he  so  choose,  by  one  or  two  light 
catgut  stitches,  which  are  soon 
absorbed.  The  parietal  wound  Fig.  234. — Ureteral  stones  (actual  size), 
should  not  be  closed  tightly,  but      which    caused    excessive    pain  and  were 

,,■,.•  V      ij       passed  by  patient  per  urethram. 

gauze  or  tubal  dramage  should     ^  -^  ^  ^ 

be  employed  for  two  or  three  days.  There  is  a  leakage  of  urine 
through  the  fistula  for  a  time,  but  if  the  operation  has  been  done 
thoroughly,  the  fistula  closes  promptly. 

I  have  described  the  most  useful  and  generally  applicable  methods 
of  dealing  with  these  stones  by  operation.  Rarely  it  may  seem  best  to 
remove  the  kidney — when  the  parenchyma  is  in  great  part  destroyed, 
when  extensive  suppuration  is  present,  and  when  a  restoration  of  func- 
tion, wdthout  the  subsequent  formation  of  stones,  seems  improbable. 

A  small  stone  causing  agonizing  pain  may  be  lodged  in  the  ureter, 
in  which  case  that  canal  must  be  explored  and  the  stone  removed.    Stone 


374  GENITO-URIXARY    ORGAN'S 

high  in  the  ureter  is  reached  by  the  latenil  incision  and  by  splitting 
longitudinally  the  ureteral  tube.  Sometimes  stone  low  in  the  ureter 
is  approached  through  the  vagina  or  through  the  bladder,  opened  above 
the  pubes.  Sometimes  a  ureteral  stone  may  bo  pushed  up  into  the 
renal  pelvis  and  reUiovcd  from  this  point,  when  the  kidney  has  been 
opened  for  stone;  or  it  may  be  possible  to  squeeze  a  ureteral  calculus 
down  into  the  bladder.  J.  H.  Gibbon  prefers  the  easy  and  simple 
approach  to  the  ureter  by  the  transperitoneal  route  through  a  short 
incision,  such  as  is  usually  made  to  find  the  vermiform  a{)pendix.  If 
one  has  opened  the  ureter,  it  may  be  closed  satisfactorily  with  fine  silk 
Lembert  stitches.  The  surgeon  nuist  drain  a  sutured  ureter  through 
the  external  wound. 

HYDRONEPHROSIS 

Hydronephrosis  is  a  dilatation  with  aseptic  urine  of  the  renal  pelvis, 
but  if  infection  take >  place,  the  contained  fluid  becomes  purulent,  and 
the  process  may  go  on  to  involvement  of  the  renal  parenchyma.  True 
hydronephrosis  is  due  to  a  mechanical  obstruction  to  the  escape  of 
urine  from  the  ureter — congenital  or  acquired  obstruction.  Congenital 
obstacles  are  rare,  such  as  imperforate  ureter  or  ureter  obstructed  by 
an  anomalous  branch  of  the  renal  artery.  The  acquired  obstacles  are 
more  common,  and  perhaps  the  most  common  of  such  obstacles  is 
kinking  of  the  ureter,  due  to  prolapse  of  a  movable  kidney.  Again, 
the  ureter  may  be  obstructed  anywhere  in  its  course  by  the  pressure  of 
tumors,  by  diseases  and  injuries  of  its  own  wall,  by  a  calculus  or  foreign 
body,  by  inflammatory  exudate  within  the  bony  pelvis,  by  disease  or 
tumor  of  the  bladder,  or  by  operative  ligation  of  the  ureter  (J.  Del- 
linger  Barney).  Such  obstructions  may  lead  to  a  great  accumulation 
of  fluid  not  only  within  the  renal  pelvis,  but  within  the  kidney  itself, 
through  great  dilatation  of  the  calices,  pouch  formations,  and  stretching 
and  thinning  of  the  parenchyma  and  capsule.  The  hydronephrotic 
tumor  may  reach  a  great  size — as  large  as  a  child's  head  even. 

False  hydronephrosis  is  a  collection  of  fluid  on  the  outside  of  the 
kidney. 

The  symptoms  of  hydronephrosis  are  gradual  and  vague  in  their 
onset,  though  one  form,  intermittent  hyrlronephrosis,  so  called,  due  to  the 
ureteral  kinking  of  movable  kidney,  is  characterized  by  recurring  at- 
tacks of  pain,  the  formation  of  a  tumor,  and  subsidence  of  the  swelling, 
with  a  sudden  abundant  discharge  of  urine  into  the  bladder.  Commonly, 
however,  hydronephrosis  is  associated  with  dull  pain  in  the  loin  and  with 
a  diminution  of  the  urine  passed.  There  is  no  fever;  gradually  a  pal- 
pable tumor  reveals  itself.  Sometimes  there  is  an  associated  histor\' 
suggesting  renal  calculus  or  the  symptoms  of  malignant  disease,  with 
its  characteristic  pain  and  cachexia.  We  establish  the  diagnosis  of 
hydronephrosis  by  observing  such  symptoms  and  feeling  a  fluctuating 
cyst. 

The  treatment  of  hydronephrosis  must  be  operative.  When  ad- 
vanced coincident  disease  is  present,  such  as  cancer  of  some  other  organ, 


PYELITIS 


375 


one  should  attempt  nothing  more  than  permanent  drainage  of  the 
renal  cyst,  in  order  to  reli(^ve  pressure  and  discomfort.  Should  the 
patient's  condition  admit,  adventitious  tumors  are  removed.  Disease 
and  injury  of  the  ureter  itself  arc  to  be  treated  by  exposing  the  ureter 
and  excising  the  damaged  portion.  In  many  cases  one  may  then  per- 
form ureteral  closure  cither  by  end-to-end  suture  or  by  implanting  the 
upper  into  the  lower  portion,  after  the  method  of  van  Hook.  Obviously, 
an  impacted  calculus,  an  obstructing  blood-clot,  or  the  rare  ureteral 
neoplasm  must  be  removed, 
and  crippling  pelvic  exuda- 
tion must  be  appropriately 
treated.  Hydronephrosis, 
due  to  kinking  of  the  ureter, 
commonly  associated  with 
movable  kidney,  sometimes 
with  an  abnormal  branch  of 
the  renal  artery,  and  inter- 
mittent symptoms,  is  an  espe- 
cially interesting  condition, 
because  its  proper  treatment 
restores  completely  the  func- 
tion of  the  kidney  at  the 
same  time  that  it  cures  the 
disease.  As  long  ago  as  1S92 
Fenger,  of  Chicago,  treated 
successfully  this  ureteral 
kinking  by  an  operative  pro- 
cedure similar  to  the  fam- 
ous Heineke-Mikulicz  pyloro- 
plasty. We  now  apply  this 
principle  to  stricture  of  the 
ureter.  At  the  same  time,  if 
the  kidney  is  movable,  we 
fix  it.  Some  surgeons  have 
provided  a  free  drainage  to 
the  renal  pelvis  by  making  an 
anastomosis  between  the  pelvis  and  the  ureter,  while  others  have 
resected  large  portions  of  the  wall  of  the  sac.  The  literature  of  this 
subject  is  extensive,  and  the  numerous  operations  proposed  are  ex- 
tremely ingenious. 

PYELITIS 

Pyelitis,  pyelonephritis,  and  suppurative  nephritis  are  conditions 
distinctly  susceptible  of  surgical  treatment.  Infections  of  the  kidney 
and  its  pelvis  come  about  through  the  blood-stream  or  by  direct  ex- 
tension from  below" — from  the  bladder  and  genitals  up  through  the 
ureter.  We  were  formerly  taught  that  all  renal  suppuration  came  from 
below,  but  it  is  now  apparent  that  this  is  not  the  case;  and  when  one 


Fig.  2.35. — Van  Hook's  method  of  lateral 
implantation  of  the  ureter:  A,  The  renal  por- 
tion of  the  ureter  split  longitudinally,  the  ends 
trimmed  so  as  to  admit  of  easy  implantation, 
and  the  loop  of  catgut  passed;  B,  showing  the 
method  of  passing  the  needles  so  as  to  draw  the 
renal  portion  into  the  vesical  portion;  C,  the  im- 
plantation completed  (Fowler). 


376 


GEXnO-lIlIXARY   ORGANS 


considers  the  excretory  function  of  the  kidney,  one  perceives  how  in- 
evitably it  is  subject  to  damage  in  connection  with  all  sorts  of  diseases. 
Pathogenic  bacteria  lodge  in  the  kidney  in  the  course  of  measles,  small- 
pox, scarlet  fever,  typhoid  fever,  and  tuberculosis;  while  the  colon  bacil- 
lus and  pus-producing  cocci  all  may  pass  through  it.  Gonorrhea,  as. 
well  as  infections  from  parturition,  are  common  causes  of  renal  sup- 
puration. A  familiar  old  term  for  these  renal  inflammations  is 
"  surgical  kidney."     We  need  not  consider  here  the  suppuration  due 


Fig.  236. — Surgical  kidney  (Warren  Museum,  Harvard). 


to  tuberculosis  and  calculi — the  commonest  of  all  forms  of  renal  sup- 
puration. 

The  progress  of  surgical  kidney  may  be  acute  or  it  may  be  chronic. 
The  disease  may  be  limited  to  the  renal  pelvis,  or  the  whole  organ  may 
be  invaded  and  rapidly  destroyed.  The  kidney  becomes  enlarged  and 
softened.  Blood  is  extravasated,  so  that  one  observes  the  general 
appearance  of  an  embolic  infarct.  The  infected  tissue  breaks  down, 
and  numerous  small  abscesses  are  formed  throughout  the  kidney;  or 
there  may  be  affusion  of  many  small  abscesses  into  a  few  great  pus- 
pockets,  so  that  the  kidney  is  changed  into  a  network  of  degenerated 
parenchyma,  partly  separating  the  abscess  cavities.     Then  the  fatty 


PYELITIS  377 

capsule  shrinks;  the  kidney  may  become  adherent  to  surrounding 
tissues;  pus  nuiy  break  out  through  the  capsule,  or  paranephritic  in- 
fection may  occur;  so  the  process  may  be  unlimited  or  limited  to  the 
pelvis  or  to  the  kidney  proper  or  to  both;  while  the  symptoms  of  the 
condition  and  its  gravity  must  depend  on  the  virulence  of  the  infection 
and  the  extent  of  the  inflammatory  reaction. 

The  symptoms  of  surgical  kidney  are  extremely  variable,  and  the 
diagnosis  may  be  correspondingly  difficult.  A  suppurative  nephritis 
of  embolic  origin  is  accompanied  by  sharp  attacks  of  renal  colic,  suggest- 
ing stone,  and,  indeed,  a  calculus  may  be  present.  After  such  an  attack 
one  finds  great  quantities  of  bacteria  in  the  urine.  Again,  with  an  in- 
fection of  gradual  onset  there  is  a  dull  ache  merely  in  the  loin,  and  a 
feeling  of  pressure.  Or  the  case  may  drag  on  for  years  without  any  pain 
whatever.  Usually  there  is  an  intermittent  fever,  which  may  iiin 
high  and  be  associated  with  chills;  there  is  almost  always  marked  im- 
pairment of  the  general  health.  There  may  be  anuria  or  an  intermit- 
tent pyuria,  in  which  latter  case  one  may  assume  that  one  of  the  kidneys 
is  unaffected,  for  between  attacks,  or  during  the  temporary  occlusion 
of  one  ureter,  the  urine  passed  from  the  bladder  may  be  perfectly  nor- 
mal. There  is  almost  always  an  enlargement  of  the  affected  kidney 
and  marked  tenderness  in  the  loin,  though,  rarely,  these  symptoms 
are  absent.  As  a  usual  thing,  however,  the  picture  is  fairly  character- 
istic and  the  diagnosis  not  difficult.  With  fever,  pain  or  aching  in  the 
loin,  pus  in  the  urine,  and  a  tumor  present,  one  makes  a  diagnosis  of 
surgical  kidney.  Cystitis  must  be  ruled  out,  and  one  may  settle  the 
question  of  cystitis  by  the  microscopic  examination  of  the  urine,  which 
shows  characteristic  renal,  pelvic,  or  bladder  cells,  depending  on  the 
source  of  the  irritation.  One  observes  also  the  absence  or  presence  of 
frequency  and  vesical  tenesmus.  An  acute  pyonephrosis  gives  a  classic 
group  of  symptoms:  sudden,  temporary  obstruction  to  the  urine,  with 
rapid  formation  of  a  painful,  tender  tumor;  then  a  clearing  up  of  the 
urine,  which  previously  contained  pus,  the  patient  meanwhile  growing 
worse.  Sometimes,  as  a  supplementary  study,  a  cystoscopic  examina- 
tion of  the  bladder,  with  segregation  of  the  two  urines,  may  be  employed, 
though  this  is  by  no  means  always  necessary.  There  is  nearly  always 
a  leukocytosis,  ranging  from  15,000  upward.  The  initial  symptoms  of 
these  renal  infections  in  recent  years  have  become  the  subject  of  special 
studies.  Through  these  studies  we  have  been  brought  to  see  that  many 
of  these  cases  formerly  known  as  surgical  kidney  develop  from  a  primary 
renal  focus,  which  should  be  attacked  early.  Acute  unilateral  septic 
infarcts  of  the  kidney  is  the  term  now  used  to  express  the  condition 
I  have  referred  to  in  this  paragraph  as  a  suppurative  nephritis  of 
embolic  origin.^  The  infection  may  be  mechanical,  by  actual  infected 
tissue  carried  to  the  kidney,  or  emboli  of  bacteria  themselves  may  be 
lodged  in  the  kidney  parenchyma.     Women  are  more  commonly  affected 

^  See  an  excellent  resume  of  this  whole  subject  by  Farrar  Cobb,  Acute  Hema- 
togenous Infection  of  One  Kidney  in  Persons  Apparently  Well,  Ann.  Surg.,  November, 
1908. 


378  GENITO-URINARY    ORGANS 

than  men.  The  infection  may  be  extremely  rapid  and  fatal,  or,  after 
a  rapid  onset,  the  symptoms  may  subside  and  the  course  become 
chronic.  The  symptoms  of  acute  unilateral  hematogenous  infection 
are  perplexing  often.  I  have  seen  patients  operated  upon  for  diseases 
of  the  bile-passages  and  of  the  stomach,  when  the  actual  trouble  was 
an  acutel)''  septic  right  kidney.  One  characteristic  point  in  differential 
diagnosis  is  the  extreme  tenderness  to  palpation  elicited  high  in  the 
costovertebral  angle,  when  the  kidney  is  affected.  On  the  other  hand, 
there  may  be  little  ])ain,  and  the  urine  may  show  little  disturbance, 
though  most  commonly  it  contains  blood.  With  such  an  onset  as  this 
the  disease,  if  not  quickly  fatal,  runs  on  into  that  course  which  I  have 
described  under  the  old-fashioned  caption  "  surgical  kidney."  The 
acute  unilateral  cases  are  alarming  and  fatal  often.  Usually  the  sur- 
geon must  operate  without  hesitation  and  remove  the  infected  kidney 
if  he  is  to  save  the  life  of  the  patient. 

Treatment  of  Surgical  Kidney. — Recently  I  saw  in  consultation 
a  young  woman  who  had  contracted  gonorrhea  five  months  previously, 
in  the  sixth  month  of  a  pregnancy.  She  was  delivered  safely  about 
three  weeks  before  I  saw  her.  She  appeared  to  do  well  for  a  week  after 
her  labor,  when  she  had  a  chill,  followed  by  a  hectic  fever,  dull  pain  in 
both  loins,  and  the  intermittent  appearance  of  pus  in  the  urine;  there 
was  no  frequency  or  tenesmus;  the  microscope  showed  no  evidence 
of  bladder  inflammation.  Both  kidneys  were  palpable  and  were  tender 
to  pressure.  The  patient  lay  languid  and  helpless  in  bed,  with  a  dull 
headache,  furred  tongue,  and  a  feeling  of  great  prostration.  I  directed 
the  application  of  hot  poultices  over  the  loins,  a  milk  diet,  the  copious 
drinking  of  spring  water,  permanent  drainage  of  the  bladder  by  an  in- 
lying catheter,  daily  bladder  irrigation,  and  a  strychnin  and  iron  tonic. 
Within  a  week  the  patient  was  convalescent. 

In  the  care  of  acute  pyelitis,  especially  bilateral  pyelitis,  such 
treatment  often  will  suffice.  Thus  the  renal  engorgement  is  dimin- 
ished, copious  excretion  of  urine  is  secured,  constant  drainage  with- 
out backing  up  in  the  bladder  is  accomplished,  and  the  patient's 
general  tone  is  maintained.  Writers  have  recommended  catheteriza- 
tion of  the  ureters  and  washing  out  with  boric  acid  of  the  renal  pelvis 
in  such  cases.  Though  such  pelvic  irrigation  often  is  effective,  I  regard 
it  as  hazardous,  and  not  frequently  or  lightly  to  be  undertaken.  In 
that  case  of  mine  the  recent  spread  of  the  infection  and  the  fact  that 
it  had  attacked  both  kidneys  rendered  an  extensive  operation  inad- 
visable, unless  as  a  last  and  desperate  remedy. 

Many  cases  of  pyelitis  and  surgical  kidney,  however,  must  be  treated 
by  operation — when  the  disease  is  long  established  and  fails  to  yield 
to  other  treatment,  or  when  the  infection  is  so  acute  and  overwhelming 
that  nothing  save  immediate  renal  drainage  or  extirpation  of  the  kidney 
offers  a  chance  of  cure.  Nephrotomy  and  nephrectomy  are  the  commonly 
employed  operations  in  cases  of  chronic  surgical  kidney.  Nephi'ec- 
tomy,  so  urgently  demanded  in  cases  of  acute  hematogenous  infections, 
seldom  is  necessary,  and  should  be  performed  in  case  of  most  extensive 


PYELITIS  379 

damage  only  in  the  cases  of  chronic  surgical  kidney.  When  this  late 
nephrectomy  is  performed,  the  surgeon  should  remove  the  ureter  at 
the  same  time,  in  order  to  anticipate  empyema  of  the  ureter;  or  he  should 
stitch  the  proximal  ureteral  orifice,  for  drainage,  into  the  external 
wound.  But  nephrotomy  is  the  operation  of  choice.  One  performs 
it  in  the  manner  I  described  when  treating  of  renal  calculus.  Split  the 
parenchyma;  open  the  calicos;  explore;  wa.sh  out  and  drain  all  abscesses 
as  well  as  the  renal  pelvis;  control  hemorrhage  during  the  operation  by  a 
temporary  ligature  about  the  vessels  of  the  hilus ;  and,  finally,  treat  the 
kidney  by  tampon  and  external  drainage.  In  the  case  of  extensive 
suppuration,  it  is  sometimes  well  to  stitch  the  two  halves  of  the  split 
kidney  separately  into  the  external  wound,  and  then  to  pack  the  kidney 
wound.  The  surgeon  must  realize  that  the  dangers  of  nephrectomy  do 
not  lie  so  much  in  the  operation  itself,  as  in  the  condition  resulting — 
the  patient  is  left  with  one  kidney  only.  After  all  these  operations  con- 
valescence is  slow  and  the  outlook  grave,  for  a  time.  One  depends  upon 
the  sound  kidney  to  do  extra  work;  but  gradually,  if  all  goes  well,  the 
crippled  kidney  itself  takes  up  its  functions  and  a  restoration  to  health 
may  be  anticipatedifi'  For  weeks  a  fistula  in  the  loin  of  operation  per- 
sists, however,  through  which  urine  is  discharged,  necessitating  abundant 
and  frequent  dressings.  Meantime  active  general  treatment  must  be 
pursued  and  the  best  of  hygiene  secured,  if  possible. 

Paranephritic  abscess  must  not  be  confounded  with  surgical  kid- 
ney. It  may  be  a  sequel  and  direct  result  of  surgical  kidney;  or  it  may 
arise  from  extraneous  causes  and  run  its  course,  leaving  the  kidney 
proper  uninvolved.  Such  a  paranephritic  abscess  a,s  follows  surgical 
kidney  I  have  already  described.  That  is  the  last  and  one  of  the  most 
alarming  complications  of  renal  suppuration,  and,  as  I  have  suggested, 
must  be  met  by  vigorous  treatment  involving  often  nephrectomy  and 
free  drainage.  The  more  common  forms  of  paranephritic  abscesses  do 
not  originate  in  the  kidney,  but  are  concerned  with  the  tissues  about 
that  organ — the  fat,  the  muscles,  and  possibly  the  peritoneum  and 
abdominal  organs.  Paranephritic  abscess  may  break  into  and  discharge 
through  one  of  the  hollow  viscera,  or  may  make  its  way  into  the  pleural 
cavity,  the  lungs,  and  bronchi.  One  observes  at  once,  therefore,  that 
the  commoner  cases  of  paranephritic  abscess  are  associated  with  little 
evidence  of  kidney  disturbance.  There  is  no  pus  in  the  urine,  and  such 
urinary  changes  as  appear  indicate  nothing  more  than  acute  renal  con- 
gestion. In  other  words,  we  have  to  deal  with  a  lumbar  abscess.  We 
find  the  usual  signs  of  abscess,  pain,  heat,  redness,  swelling,  and  fever. 
The  only  proper  treatment  is  free  drainage.  With  this,  usually,  the 
inflammation  subsides  and  little  more  is  necessary  for  the  treatment 
of  complications  even.  Fistulse  gradually  close  and  the  patient  re- 
turns to  a  normal  condition.  In  the  after-treatment  I  sometimes  em- 
ploy large,  hot  creolin  poultices,  applied  every  three  hours,  but  generally 
a  dry  gauze  dressing  suffices.  I  have  found  prolonged  immersion  of  the 
patient  in  a  hot-water  bath  to  be  a  great  comfort  to  him  sometimes, 
when  the  inflammation  was  subsiding  slowly,  and  an  irritating  open 


380 


GENITO-URINARY    ORGANS 


wound  persisted  for  a  long  time.  If  such  bath  treatment  comforts  and 
rehcves  the  sufferer,  one  may  feel  confident  that  a  cure  is  being  hast- 
ened. 

TUBERCULOSIS   OF   THE   KIDNEY 

Let  us  consider  briefly  this  most  common  and  most  interesting  form 
of  renal  infection.  Primary  tuberculosis  of  the  kidney  is  probably 
rare.  The  infecting  organisms  generally  reach  the  kidney  through  the 
blood-stream,  being  taken  up  from  foci  in  the  chest,  the  abdomen,  or 
elsewhere.  It  was  not  long  ago  that  we  believed  all  renal  tuberculosis 
to  be  an  ascending  process  from  the  bladder  and  genital  organs,  but 


Fig.  2.37.— Tuberculous  kidney  (Warren  Museum,  Harvard). 

there  is  now  abundant  evidence  that  this  source  of  infection  is  not  so 
common  as  that  through  the  blood-stream.  Infection  through  the  blood- 
stream shows  itself  usually  in  one  kidney,  rarely  in  both.  Infection 
through  the  genital  tract  seizes  upon  both  kidneys.  Fortunately  for 
patients  and  surgeons,  the  blood-stream  source  is  the  commoner, 
and  unilateral  renal  tuberculosis  is  more  frequent  than  bilateral  tuber- 
culosis. 

The  disease  is  insidious  usually,  though  it  may  develop  rapidly 
in  the  course  of  a  general  tuberculosis.  The  pathologic  process  is 
similar  to  tuberculosis  elsewhere.     Small   foci  appear  in  the  paren- 


TUBERCULOSIS    OF   THE    KIDNEY  381 

chyma  of  the  organ;  they  spread,  caseate,  break  down,  and  run  to- 
gether. Frecjuently  a  mixed  infection  supervenes;  abscesses  form, 
the  parcnch^-ma  of  the  organ  is  destroyed;  the  morbid  process  gives 
rise  to  a  considerable  tumor,  and  sometimes  extensive  adhesions  develop ; 
frequently  calculi  are  deposited,  and  the  ureter  is  invaded  by  tubercu- 
lous invasion.  That  involvement  of  the  ureter  is  an  important  fact. 
The  tube  becomes  thickened,  narrow,  inelastic,  and  extensively  adherent. 
Total  occlusion  may  take  place,  with  a  resulting  coincident  pyonephro- 
sis and  distention  of  the  ureter  itself.  The  kidney  is  thrown  out  of 
action,  though  long  before  this  situation  is  reached  it  may  have  been 
functionless. 

Such  is  a  picture  of  advanced  renal  tuberculosis.  This  stage  may 
be  attained  in  a  few  months,  or  the  disease  may  run  on  for  years,  chang- 
ing little  in  its  pathologic  aspects. 

It  must  be  obvious  to  the  reader  who  has  made  himself  familiar 
w'ith  the  curiosities  and  amenities  of  pathology — it  must  be  obvious 
to  such  a  reader  that  the  symptoms  of  renal  tuberculosis  will  probably 
keep  pace  with  the  morbid  changes,  while,  at  the  same  time,  a  diagnosis 
may  be  extremely  difficult,  or  may  be  instantly  apparent.  I  protest 
that  an  early  diagnosis  is  imperative,  for  M'e  can  often  cure  the  cases 
taken  early.  We  look  for  characteristic  constitutional  symptoms: 
emaciation,  cachexia,  hectic  fever,  sweating,  rapid  pulse,  furred  tongue, 
distaste  for  food,  and  anemia.  Generall}',  there  is  bladder  irritation, 
with  tenesmus  and  frequency.  The  urine  may  be  clear,  or  may  be 
loaded  with  pus,  and  sometimes  with  blood.  One  is  often  disappointed 
in  the  physical  examination  of  such  patients.  One  expects  to  see  a 
pallid,  emaciated  victim,  but  such  appearances  come  late.  I  have 
found  renal  tuberculosis  in  plump,  active,  red-cheeked  girls,  in  whom 
the  disease  had  not  been  suspected.  Often  one  finds  a  tumor  in  the 
loin,  enlarged  glands  in  the  axilla,  groin,  or  neck,  and  perhaps  scars  on 
the  bod}-.  In  the  case  of  a  woman  one  may  feel  by  vagina  an  enlarged, 
cord-like  ureter  on  one  side,  passing  in  front  of  the  cervix.  Some- 
times in  thin  persons  of  either  sex  the  thickened  ureter  may  be  felt 
through  the  abdominal  wall.  Examine  the  urine.  Look  for  tubercle 
bacilli  in  the  sediment.  As  a  confirmatory  test  inject  some  of  the  urin- 
ary sediment  into  a  guinea-pig.  It  takes  from  three  to  four  weeks  for 
tuberculosis  to  develop  in  the  animal.  Examination  with  the  cysto- 
scope  is  informing,  and  one  maj'  thus  determine  the  source  of  the  pus, 
whether  from  right  or  left  ureter  or  from  the  bladder.  That  deter- 
mination of  right  or  left  is  vital. 

The  most  experienced  surgeon  may  be  misled  by  sj-mptoms  alone, 
and  may  pronounce  a  left  kidney  tuberculous  when  the  right  is  at 
fault. 

Thus  we  make  the  diagnosis,  observing  especially  pain,  tumor, 
pus,  and  blood,  and  taking  into  account  the  hectic  fever  and  the  nature 
of  the  urinar}^  sediment.  And  we  must  remember  that  calculi  may  be 
present  to  befog  us,  while  surgical  kidney  has  many  factors  in  common 
with  tuberculous  kidney. 


382  GENITO-UKINAUY    OllGANS 

The  treatment  of  renal  tuberculosis  still  agitates  surgeons,  though 
many  are  coming  into  some  manner  of  accord.  Not  long  ago  we  thouglit 
the  disease  could  be  checked  or  cured  by  an  out-of-door  life.  Doubtless 
this  is  often  true,  but  it  is  impossible  to  secure  such  a  life  for  the  ma- 
jority of  patients.     Many  cannot  find  it,  and  many  will  not  follow  it. 

The  surgeon  must  prescribe  carefully  the  mode  of  life  and  proper 
hygiene,  nutritious,  fattening  foods  and  iron  for  every  patient,  whether 
or  not  an  operation  be  undertaken.  Now,  that  question  of  operating 
is  no  longer  the  extremely  doubtful  question  that  it  was  a  few  years 
ago.  Most  tuberculous  kidneys  must  be  operated  upon,  and  the  sooner 
the  better.  The  probability  of  cure  or  arrest  of  the  disease  iriifiout 
operation  is  not  nearly  so  great  as  in  the  cases  of  pulmonary  or  joint 
tuberculosis.  As  a  rule,  removal  of  the  kidney  is  the  operation  of 
choice,  for  thus  alone,  in  most  cases,  can  we  assure  ourselves  that  the 
whole  disease  has  been  extirpated.  If  the  kidney  is  small,  it  is  well  to 
follow  Kelly's  method  and  approach  the  organ  through  the  posterior 
lumbar  triangle;  or  one  may  operate  by  the  lateral  flank  incision. 
Examine  carefully  the  ureter  and  remove  it  also.  Partial  nephrectomy 
occasionally  produces  a  cure,  but  in  order  to  excise  satisfactorily  a 
portion  of  the  kidney  one  must  be  sure  that  the  tuberculosis  is  limited 
to  one  pole,  and  this  can  be  ascertained  only  by  a  searching  nephrotomy 
— a  splitting  the  kidney  from  end  to  end,  and  making  sure  that  unsus- 
pected foci  do  not  lurk  somewhere  in  the  organ.  In  the  case  of  advanced 
disease,  when  the  kidney  is  greatly  enlarged,  it  may  be  difficult  or  im- 
possible to  remove  it  at  once,  entire.  In  such  a  case  one  may  empty 
the  sac  by  nephrotomy,  and  then,  at  a  second  sitting,  extirpate  the 
diminished  organ.  Always  in  such  cases  one  must  detach  with  care  the 
upper  pole,  on  account  of  possible  adhesions  to  the  vena  cava  and  the 
duodenum.  In  all  cases  one  should  be  sure  of  the  condition  of  the 
opposite  kidney — whether  or  not  it  be  present,  free  from  disease,  and 
functionating.  The  removal  of  one  kidney  when  its  fellow  is  tuber- 
culous is  extremely  hazardous  and  is  commonly  useless.  Tuberculosis 
of  the  bladder,  however,  is  not  necessarily  a  contraindication  to  neph- 
rectomy.    Always  remove  the  diseased  ureter. 

The  results  of  these  radical  operations  for  tuberculous  kidney  are 
often  extremely  satisfactory.  When  the  disease  is  seen  earl}-  and  is 
limited,  the  patient  may  recover  perfectly  through  the  operation. 

TUMORS  OF   THE  KIDNEY  AND   SUPRARENAL  GLAND 

Hypernephroma  is  the  most  interesting  of  kidne}'  new-groAvths. 
Although  P.  Grawitz  described  and  named  hypernephroma  so  long  ago 
as  1883,  within  recent  years  only  has  the  profession  at  large  recognized 
the  significance  of  the  disease.  Every  surgeon  of  experience  can  re- 
member operating  upon  malignant  tumor  (sarcoma)  of  bone  in  cases 
in  which  renal  symptoms  and  kidney  tumor  subsequently  have  appeared. 
Strangely  enough,  the  association  between  these  tumors  of  bone  and 
tumors  of  the  kidney  for  long  went  unrecognized.     Indeed,  only  last 


TUMORS    OF    THE    KIDNEY    AND    SUPRARENAL    GLAND  383 

year  I  saw  the  specimen  of  a  sarcoma  of  the  clavicle  removed  by  a  sur- 
geon who  had  failed  to  investigate  the  condition  of  the  kidneys.  After 
the  excision  of  the  bone  tumor  he  discovered  a  considerably  enlarged 


Fig.  238. — Plypernephroma. 

right  kidney.     So  we  see  that  bone  metastasis  is  one  of  the  significant 
features  of  hypernephroma. 

Grawitz  gave  the  name  to  the  disease.  Frequently  at  postmortem, 
on  stripping  back  a  kidney  capsule,  one  finds  beneath  the  capsule  small, 
fat-like  bodies,  the  size  of  a  pea  or  less.     Grawitz  pointed  out  that 


384  GENITO-URINAUY    ORGANS 

these  are  inclusions, — portions  of  the  suprarenal  gland, — that  they  may 
remain  indefinitely  -without  causing  damage,  or  that  at  any  time  during 
life  they  may  take  on  growth  and  develop  into  consideraljle  tumors — 
sometimes  benign,  sometimes  malignant.  These  tumors  are  histologic- 
ally characteristic,  showing  a  delicate  vascular  stroma,  within  the  meshes 
of  which  are  strings  or  groups  of  polygonal  cells,  whose  bodies  contain 
few  or  many  fat-drops;  in  their  stnicture  and  in  the  character  of  their 
cells  these  nodules  resemble  closely  the  nodules  which  develop  in  the 
suprarenal  gland.  One  never  can  tell  at  what  moment  hyperne]:)hroma 
may  bring  forth  metastases.  If  the  growth  remain  localized,  one  may 
regard  it  as  benign.  If  it  spread  so  as  to  involve  other  organs, — es- 
pecially if  growths  of  similar  structure  appear  in  distant  bones, — it  has 
become  malignant, — one  of  the  most  malignant  forms  of  tumor.  Ob- 
viovisly,  therefore,  as  soon  as  hypernephroma  is  discovered  in  the  kidney, 
the  whole  organ  should  be  extirpated. 

The  symptoms  of  hypernephroma  are  no  more  characteristic  than 
are  the  symptoms  of  other  renal  diseases,  but  the  following  i-henomena 
are  fairly  constant:^  recurring  attacks  of  hemorrhage  associated  with 
frequency  of  urination,  often  associated  with  clots  which,  in  their 
journey  through  the  ureter,  stop  the  stream  (for  hours  or  days,  as  shown 
by  diminishing  amount  of  urine),  and  cause  fairly  severe  pain.  Between 
the  hemorrhages  are  periods  not  characterized  by  ''  frequency,"  but 
by  a  diminished  amount  of  urine  and  urea,  and  marked  pain  in  the  back, 
which  persists  until  it  disappears  coinciclentally  with  the  onset  of  fresh 
hemorrhage.  These  alternations  of  pain  and  hemorrhage  are  quite 
different  from  the  symptoms  of  renal  calculus.  The  urine  generally 
shows  nothing  characteristic  when  submitted  to  the  usual  tests.  The 
further  symptoms  for  which  one  looks  are  those  common  to  ad- 
vancing tumor-formation — pain,  cachexia,  and  metastasis.  The  phy- 
sical examination  reveals  a  kidney  but  little  enlarged  at  times,  though 
frequently  the  organ  reaches  a  great  size.  The  general  kidney  outline 
is  retained,  and  usually  the  surface  is  nodular.  The  diagnosis  is  sug- 
gested by  the  hemorrhages,  alternating  pain,  and  a  tliminished  urea; 
by  finding  a  tumor,  and  by  the  discovery  of  malignant  disease  of  bone. 

The  treatment  of  hypernephroma  is  immediate  nephrectomy, 
wdth  a  prognosis  always  doubtful.  Some  patients  have  survived  in 
health  many  years  after  the  operation;  some  quickly  have  fallen  vic- 
tims to  metastasis. 

Sarcoma  of  the  kidney  often  can  scarcely  be  distinguished  from 
hypernephroma — indeed,  all  tumors  of  the  kidney,  whether  benign  or 
malignant,  closely  resemble  each  other  clinically.  Sarcoma  develops 
in  children  and  in  persons  of  middle  age.  It  often  grows  rapidly,  and 
varies  in  malignancy  according  as  do  itshistologic  components.  Usually 
spindle-celled  or  large-celled  or  round-celled,  it  may  exist  as  a  single 
tumor,  or  there  may  be  multiple  tumors.  Freciucntly  there  are  mixed 
forms  of  sarcoma,  such  as  fibrosarcoma,  and  some  of  these  tumors  are 

1  P.  Thorndike  and  J.  H.  Cunningham,  Hypernephroma,  Boston  Med.  and  Surg. 
Jour.,  December  .3,  1903. 


TUMORS    OF   THE    KIDNEY    AND    SUPRARENAL    GLAND  385 

relatively  benign.  Then  there  is  the  angiosarcoma  which  goes  by 
various  names,  endotheUoma  among  others.  Sarcomata  do  not  often 
bleed.  They  rarely  obstruct  the  ureter.  They  invade  the  veins — 
especially  the  renal  vein — and  deposit  metastases  in  distant  parts  of 
the  body.  Rarely  sarcomata  may  be  bilateral.  Ordinarily,  when  one 
kidney  only  is  affected,  an  attempt  at  its  extirpation  should  be  made, 
though  this  is  possible  early  in  the  disease  only.  In  this  connection 
G.  Walker  ^  advocates  tying  the  renal  vessels  by  transperitoneal  section 
before  removing  the  kidney  through  an  extraperitoneal  route.  One 
opens  the  abdomen  in  the  median  line,  seeks  the  renal  vessels,  and  cuts 
down  upon  them  through  the  posterior  peritoneum;  then  secures  them 
by  double  ligatures,  closes  the  peritoneum,  and  attacks  the  kidney  by 
the  lateral-flank  or  lumbar  incision.  These  malignant  tumors  are  best 
removed  by  an  extraperitoneal  route,  for  transperitoneal  extirpation 
shows  a  3  per  cent,  higher  death-rate. 

At  the  best  the  outlook  for  sarcoma  of  the  kidney  is  grave. 

Carcinoma  of  the  kidney  is  another  rapidly  fatal  disease.  The 
growth  originates  in  the  uriniferous  tubules  and  gradually  destroys  the 
parenchyma,  invading  in  turn  the  renal  vessels,  the  ureter,  and,  rarely, 
the  bladder.  Though  sometimes  primary  in  the  kidney,  cancer  is  much 
more  often  secondary  there.  It  is  characterized  by  pain,  hemorrhage,' 
cachexia,  and  metastasis.  Sometimes,  if  situated  in  the  upper  pole, 
it  cannot  be  recognized  until  far  advanced;  but  when  in  the  lower  pole, 
it  is  palpable  early. 

Extirpation  is  the  only  logical  treatment  for  renal  cancer,  though  the 
outlook  is  even  more  grave  than  in  the  case  of  sarcoma,  and  the  opera- 
tive mortality-rate  is  as  high  as  50  per  cent. 

There  are  numerous  non-malignant  tumors  of  the  kidney,  but  they 
are  relatively  rare,  and  often  are  not  discovered  clinically.  A  long  list 
of  such  tumors  is  given  by  compilers  of  statistics:  fibroma,  lipoma, 
osteoma,  chondroma,  angioma,  and  lymphangioma,  all  of  which  cause 
symptoms  through  their  size  and  by  compression  of  other  organs.  It 
is  impossible  to  differentiate  them,  but  they  may  be  treated  success- 
fully by  nephrotomy  or  nephrectomy. 

There  are  also  cystic  tumors  of  the  kidney.  Simple  cysts  show 
little  tendency  to  destroy  renal  tissue,  and  are,  therefore,  harmless. 
Echinococcus  cysts  are  uncommon.  They  develop  slowly  and  give  little 
pain.  The  diagnosis  is  impossible  unless  one  of  the  cysts  bursts,  when 
daughter-cysts  and  booklets  may  be  found  in  the  urine.  The  disease 
is  cured  by  incision  and  drainage  in  a  considerable  proportion  of  cases. 
Polycystic  degeneration  may  transform  the  kidney  into  a  mass  of  cystic 
spaces,  large  and  small,  with  obliteration  of  parenchyma.  The  process 
may  be  congenital  ^  or  may  originate  late  in  life  and  run  a  chronic  course. 
The  disease  is  bilateral  usually.  Nephrectomy  is  permissible  in  case  the 
opposite  kidney  is  proved  competent.     Probably  the  best  operation  is 

1  Jour.  Amer.  Med.  Assoc,  November  25,  1905. 

2  See  especially  F.B.  Lund,  Congenital  Cystic  Kidney,  Jour.  Amer.  Med.  Assoc, 
August  18,  1906. 

25 


386  GENITO-URINARY    ORGANS 

nephrotomy:  a  breaking  up  of  the  cysts  and  suture  to  the  himbar 
muscles,  with  packing  and  abundant  drainage. 

A  clas^sification  of  tumors  of  the  suprarenal  glands  is  still  imperfect. 
Probably  80  per  cent,  of  suprarenal  lesions  are  tuberculous.  There  are 
rare  cases  of  primary  cancer  and  sarcoma/  Avhile  adenoma  is  more  com- 
mon. Adrenal  cysts  occasionally  are  reported,  while  adrenal  hema- 
toma in  the  new-born  is  not  uncommon.  Some  adrenal  cysts  may  attain 
great  size  and  require  an  extensive  surgical  operation  for  their  removal. 
If  complete  extirpation  is  impossible  on  account  of  hemorrhage  and  ex- 
tensive adhesions,  the  surgeon  may  resort  to  marsupialization.- 

LUMBAR   FISTULA 

Fistula  in  the  renal  region  may  be  a  cause  of  obstinate,  dangerous, 
and  distressing  symptoms.  There  are  various  types  of  these  fistulse. 
Some  of  them  are  not  connected  with  the  kidney.  Perhaps  the  fistula 
most  commonly  seen  is  that  which  persists  after  a  surgical  operation — 
generally,  a  nephrotomy  for  hydronephrosis  or  for  calculus.  FistuljE 
may  be  associated  w^ith  tuberculosis.  The  presence  of  a  calculus,  of 
diseased  cystic  renal  walls,  of  tuberculosis,  or  of  ureteral  stone  may  cause 
fistulse  to  persist  indefinitely.  Those  fistuke  which  do  not  communi- 
cate with  the  renal  apparatus  may  mark  the  site  of  an  old  parane- 
phritic abscess. 

Curious  internal  fistulse  are  seen  sometimes — fistulse  connecting  the 
kidney  with  the  intestine  (intestinorenal,  usually  colon)  or  with  the 
stomach  (gastrorenal) ;  and  in  these  cases  pus  and  urine  will  escape  by 
the  rectum,  or  undigested  food  may  be  passed  from  the  bladder. 

The  treatment  of  these  intricate  conditions  is  by  painstaking  and 
laborious  operation.  The  urinary  passages  must  be  explored,  foreign 
substances  removed,  necrotic  tissue  excised,  and  kidneys,  tuberculous 
or  obstinately  diseased,  must  be  extirpated.  At  the  same  time  the 
fistulous  track  must  be  explored  and  damaged  viscera  repaired. 

CHRONIC  NEPHRITIS 

Within  the  last  ten  3-ears  decapsulation  of  the  kidney  has  been 
employed  for  the  cure  of  chronic  nephritis.  Ferguson  has  made  some 
interesting  and  valuable  observations  on  the  subject,  while  Edebohls, 
in  vigorous  language,  has  advocated  the  measure.  Many  operators 
have  experimented  with  kidney  decapsulation  for  renal  inflanmiations, 
so  that  the  statistical  reports  now  at  our  disposal  are  considerable. 
Unfortunate!}',  conclusive  evidence  as  to  the  value  of  decapsulation  is 
not  yet  before  us.  There  seems  to  be  little  doubt  that  many  cases  have 
been  improved,  and  that  some  few  cases  have  been  cured,  by  this  man- 
euver; but  the  final  application  of  the  measure  to  definite  conditions  is 
not  yet  clear  enough  to  be  taught  in  a  brief  treatise  of  this  nature. 

1  See  Ramsay,  Johns  Hopkins  Hosp.  Bull.,  1902,  vol.  x. 

2  Cysts  of  the  Suprarenal  Gland,  Andrew  J.  McCosh,  Ann.  Surg.,  June,  1907. 


(HKONIC    NEPHRITIS  387 

The  technic  of  kidney  decapsulation  is  extremely  simple.  The 
surgeon  approaches  the  kidney  through  a  lumbar  incision,  as  though 
he  purposed  nephropexy.  He  seizes  and  extracts  the  kidney,  splits  the 
fibrous  capsule,  peels  it  off,  and  removes  it  as  far  down  as  the  renal 
vessels.  He  then  drops  back  the  kidney  into  its  place.  The  nature 
of  the  histologic  changes  which  follow  in  the  course  of  healing  is  still 
under  discussion,  and  numerous  ingenious  observers  have  advanced 
various  views.  Whatever  takes  place,  it  is  certain,  as  I  have  stated, 
that  relief  sometimes  ensues,  owing  probably  to  the  removal  of  pressure 
from  the  tense  kidney  tissue. 

In  the  foregoing  pages  I  have  outlined  the  most  frequent  pathologic 
conditions  in  the  kidney  which  concern  the  surgeon.  Often  they  are 
related  closely  to  disturbances  in  other  parts  of  the  urinary  tract,  and  I 
shall,  therefore,  in  the  next  chapter,  continue  the  discussion,  dealing 
especially  with  diseases  of  the  bladder  and  prostate  gland. 


CHAPTER  XIV 

BLADDER  AND   PROSTATE 

The  Bladder 

Through  the  development  of  surgery  it  has  come  about  that  the 
bladder  interests  surgeons  less  than  it  did  in  the  last  generation.  In 
current  periodic  literature  discussion  of  bladder  diseases  is  not  conspic- 
uous, yet  in  my  student  days  stone  in  the  bladder  was  held  to  be  one  of 
the  most  important  subjects  of  surgical  investigation,  and  the  literature 
of  vesical  calculus  was  enormous.  Doubtless  this  interest  was  due-  in 
part  to  the  genius  of  Henry  J.  Bigelow,  who  then  recently  had  thrown 
upon  the  subject  a  flood  of  light,  and  had  advanced  the  operation  for 
stone  from  its  long-time  perilous  position  to  a  situation  of  safety  and 
certainty.  All  that  is  now  ancient  history.  Surgeons  are  somew'hat  tired 
of  bladder  problems.  The  bladder  is  not  a  vital  organ,  so  that  the  pres- 
ervation of  its  structure  and  function  is  less  urgently  important  than 
is  the  case  with  the  kidney  and  the  intestine.  Indeed,  individuals  can 
get  along  without  a  urinary  bladder.  Unfortunate  wretches  are  not 
infrequently  born  without  a  proper  bladder.  Such  persons  present  the 
condition  known  as  exstrophy  of  the  bladder. 

EXSTROPHY  OF   THE  BLADDER 

This  curious  condition,  which  amounts  practically  to  an  absence 
of  the  bladder,  is  a  congenital  defective  development  seen  more  commonly 
in  male  than  in  female  infants.  The  anterior  abdominal  wall  fails  to 
close,  and  the  anterior  v.'all  of  the  bladder  is  absent,  so  that  the  pos- 
terior bladder-wall,  with  the  openings  of  the  ureters,  presents.  The 
arch  of  the  pubes  is  undeveloped,  epispadias  exists,  and  frequently 
the  testicles  do  not  descend.  As  a  result  of  this  condition  the  posterior 
vesical  mucosa  protrudes  into  the  outer  world,  and  urine  constantly 
dribbles  from  the  exposed  ureters.  The  condition  of  the  victim  is 
loathsome. 

There  are  various  degrees  of  exstrophy,  from  a  mere  trifling  open- 
ing or  cleft  in  the  lowest  portion  of  the  bladder  to  a  wide  furrow,  exposing 
bladder,  urachus,  and  urethra.  It  is  obvious  that  the  condition  is  found 
in  poorly  developed  and  congenitally  defective  subjects,  and  one  ques- 
tions sometimes  whether  the  lives  of  the  unfortunate  victims  are  worth 
saving. 

The  only  reasonable  treatment  consists  in  some  form  of  surgical 
operation  which  shall  confine  the  urine  in  its  normal  channel,  or  at  least 
divert  it  from  constantly  flowing  over  the  parts.     The  names  of  sundry 

388 


ABSENCE    OF    HLADDEIi;    DOUBLE    BLADDER  389 

distingui.shc(l  siirfj;eons  have  been  connected  with  endeavors  to  relieve 
exstrophy  of  the  hhulder.  Until  recently  the  aim  of  all  was  to  restore 
the  anterior  bladder-wall  by  turning  skin-fhips  over  the  defects — skin- 
flaps  with  the  epithelium  turned  in.  These  efforts  have  not  been  satis- 
factory. A  continent  bladder  practically  never  is  secured  in  this  manner. 
Trendelenburg  advocates  bringing  together  the  separated  pubic  bones 
after  dividing  the  sacro-iliac  synchondroses.  Tlie  maneuver  is  hazar- 
dous, and  the  results  uncertain.  Certain  surgeons  advocate  removing 
the  bladder  altogether  and  implanting  the  ureters  in  the  urethra. 
This  operation  is  not  difficult,  nor  is  it  dangerous.  It  confines  the 
urinary  stream  to  a  normal  passage,  from  which  the  continual  drippings 
may  be  collected  in  a  suitable  urinal.  Of  recent  years  a  more  radical 
operation  for  exstrophy  has  been  advocated  by  various  ingenious 
writers,  and  their  questionable  successes  have  roused  some  spasmodic 
enthusiasm.  Simon,  Maydl,  Gersuny,  Hochenegg,  Peters,  Rutkowski, 
and  .others  have  advocated  extirpating  the  bladder  and  implanting 
th«  ureters  in  the  rectum,  the  sigmoid,  or  the  ileum.  Maydl's  method 
is  intraperitoneal;  Peter's  method  is  extraperitoneal,  and  there  are 
sundry  modifications.  The  ureters  with  a  portion  of  the  trigone  are 
excised  and  implanted  within  the  gut.  Bottomley  advocates  vigorously 
the  implanting  of  the  ureters  in  the  skin  of  the  loin  behind  the  kidneys. 
Experience  shows  that  urine  escaping  in  the  back  is  easily  collected 
in  a  suitable  apparatus,  to  the  great  comfort  of  the  patient.  As  a 
secondary  step  in  his  operation,  Bottomley  excises  the  remnant  of  the 
bladder.^  Several  of  these  patients  have  recovered  and  have  led  fairly 
comfortable  existences  for  a  time.  Probably  some  form  of  transplan- 
tation operation  is  the  operation  of  choice,  though  the  cases  are  as  yet 
too  few  for  us  to  know  definitely  the  probable  mortality  from  ascending 
pyelitis,  the  tolerance  of  the  bowel,  and  the  competency  of  the  anus  in 
those  cases  in  which  the  ureters  are  implanted  in  the  rectum. 

ABSENCE  OF  BLADDER;  DOUBLE  BLADDER 

Two  other  rare  anomalies  of  the  bladder  are  congenital  absence  of 
the  bladder  and  double  bladder. 

The  most  common  lesions  of  the  bladder  are  inflammations,  calculus 
formation,  and  tumors,  and  the  most  noticeable  and  important  symp- 
tom for  ^vhich  the  surgeon  is  consulted  is  retention  of  urine  due  to 
some  obstruction  to  the  bladder's  outlet.  As  with  the  kidney,  similar 
bladder  symptoms  may  be  due  to  divers  causes,  while  similar  causes  may 
produce  various  symptoms;  retention  of  urine  may  be  due  to  stricture 
of  the  urethra  or  to  prostatic  hypertrophy,  while  stricture  of  the  urethra 
may  cause  no  other  symptoms  than  frequency,  and  prostatic  hypertrophy 
may  be  devoid  of  all  symptoms  whatever. 

Let  us  consider  first  the  familiar  symptom,  retention  of  urine,  and 
after  that,  the  conditions  which  give  rise  to  retention. 

1  John  T.  Bottomley,  Operati^-e  Treatment  of  Exstrophy  of  the  Bladder  by 
Transplantation  of  the  Ureters  on  to  the  Skin  of  the  Loin,  Jour.  Amer.  Med.  Assoc, 
July  13,  1907.     Bottomley  gives  an  excellent  bibliography  also. 


390  GENITO-URINARY   ORGANS 

RETENTION   OF  URINE 

The  condition  of  retention  is  an  abnormal  collection  of  urine  within 
the  bladder  due  to  the  more  or  less  complete  obstruction  of  the  natural 
outlet.  We  recognize  comi)lete  retention  and  ])artial  retention,  par- 
tial retention  b(Mng  the  more  common,  for  complete  retention  must  be 
regarded  generally  as  the  last  stage  of  a  long-continued  partial  retention. 
A  majority  of  cases  of  retention  are  due  to  some  such  obstruction  as  I 
have  mentioned, — obstruction  of  the  urethra, — though  there  is  a 
second,  rarer  variety  of  retention  in  which  the  condition  results  from 
some  diminution  of  vigor  in  the  expulsive  forces — some  paralysis  or 
other.  Urethral  stricture  and  prostatic  enlargement  are  the  most 
common  causes  of  obstruction.  In  addition,  retention  may  be  due  to 
acute  inflammation  causing  swelling  and  choking  of  the  urethra;  to 
prostatic  tuberculosis;  to  concretions;  to  abscess  or  tumors;  to  lacera- 
tions of  the  urethra,  or  to  blood-clots  and  foreign  bodies.  Some  modi- 
fication of  nervous  force  diminishing  the  expulsive  power  of  the  bladder 
gives  rise  to  a  common  form  of  retention.  For  example,  many  persons, 
while  lying  on  the  back,  cannot  void  urine;  operations  upon  the  abdomen 
and  pelvis  frequently  cause  such  temporary  retention.  Moreover,  there 
are  the  more  general  causes  which,  through  sundry  diseases,  affect  the 
tone  of  the  bladder,  and  there  are  special  diseases  resulting  in  paralyses — 
such  diseases  as  brain  tumor  and  paresis.  If  the  surgeon  finds  a  j^atient 
with  urine  dril)bling  drop  by  drop  from  the  urethra,  he  must  not  con- 
clude that  retention  is  absent,  but  must  regard  this  dribbling  as  the 
overflow  of  an  incompetent  and  overdistended  bladder.  In  such  case 
the  presence  of  the  distended  bladder  usually  is  obvious.  It  feels 
like  a  tense,  smooth,  football-like  tumor,  rising  from  behind  the  pubes 
as  far  as  the  navel  often.  The  surgeon  must  distinguish  carefully 
retention  from  suppression  of  urine.  In  the  latter  case  no  urine  collects 
in  the  bladder;  and  he  must  recognize  rupture  of  the  bladder,  in  which 
case  urine  cannot  pass  through  the  urethra,  but  is  disseminated  through- 
out the  soft  tissues  of  the  pelvis,  a  condition  known  as  extravasation 
of  urine. 

The  reader  will  see  from  this  description  of  retention  that  its  mani- 
fold causes  demand  manifold  treatment.  The  nervous  cases  often  can 
be  set  right  by  some  simple  device — by  applying  hot,  wet  cloths  over 
the  bladder  and  perineum,  so  as  to  relax  spasm;  by  immersing  the  pa- 
tient in  a  warm  bath  and  directing  him  to  pass  urine  in  the  tiib;  by  the 
suggestion  trick  of  pouring  water  slowly  from  a  height  into  a  basin; 
by  giving  a  small  opium  suppository  (gr.  ^),  or  even  by  allowing  the 
patient,  if  proper,  to  sit  up  or  stand  for  a  few  minutes.  Such  devices, 
however,  often  fail,  in  which  case,  as  well  as  in  cases  of  organic  obstruc- 
tion, it  is  necessar}^  to  resort  to  the  common  panacea  for  retention — 
catheterization. 

When  there  is  no  obstruction  in  the  urethra,  it  is  easy  usually  to 
pass  a  catheter,  and  the  best  instrument  for  general  use  is  the  flexible 
soft-rubber  catheter  (No.  8,  10,  or  12,  English  size).     In  the  case  of  a 


RETENTION   OF    URINE  391 

woman,  the  nurse  must  have  the  patient's  thighs  widely  separated,  and 
must  part  the  vulva  with  the  fingers,  when  the  pouting  orifice  of  the 
urethra  will  appear  immediately  above  the  vaginal  outlet  and  below  the 
clitoris.  Then  the  catheter,  sterilized  by  boiling  and  well  lubricated, 
readily  may  be  passed  into  the  bladder.  Neglect  of  these  various 
details  leads  often  to  trouble  and  misery.  Not  long  ago  I  was  called 
hastily  to  a  suburban  sanatorium,  in  the  middle  of  the  night,  by  the 
physician  resident  there,  who  informed  me  that  he  wished  me  to  see  a 
maniacal  woman  who  was  in  agony  with  an  overdistended  bladder, 
which  he  was  unable  to  relieve.  On  reaching  the  patient's  room  I  had 
her  brought  to  the  edge  of  the  bed,  and  held  firmly  in  the  lithotomy 
position.  Then,  upon  parting  the  vulva,  with  a  good  Hght  behind  me,  I 
had  no  difficulty  in  emptying  the  bladder  at  once  with  an  ordinary  soft 
catheter.  It  appeared  that  the  physician  had  attempted  the  maneuver 
aided  by  the  sense  of  touch  only,  and  had  succeeded  merely  in  passing 
the  catheter  into  the  vagina.  If  for  any  reason  a  soft  catheter  fails  to 
pass,  it  is  well  to  try  a  gum-elastic  instrument  or  a  glass  or  silver  catheter. 
In  the  case  of  a  man  with  spasmodic  retention,  thq  passage  of  the 
catheter  generally  is  extremely  easy.  The  soft-rubber  instrument 
suffices  and  can  be  carried  quickly  and  directly  to  the  bladder  without 
difficulty.^ 

The  student  will  learn  the  use  of  catheters  in  his  dispensary  studies 
and  from  text-books  on  operative  surgery.  Suffice  it  here  to  suggest  a 
few  principles :  so  far  as  possible  use  soft  catheters ;  never  employ  force  ; 
remember  that,  in  the  male,  the  penis  is  held  in  such  a  position  that 
the  urethra  resembles  in  its  course  the  letter  J ;  an  extremely  service- 
able catheter  is  the  so-called  English  gum-elastic,  carrying  a  stilet 
which  can  be  bent  to  any  desired  angle;  the  so-called  coude  catheter, 
which  has  an  obtuse  elbow  near  the  beak,  is  a  useful  instrument  also; 
the  silyer  catheter  is  not  often  used  in  these  days ;  the  beak  of  a  catheter 
meets  obstiTiction  just  beyond  the  bulbous  urethra,  and  often,  in  old 
men,  in  the  prostatic  urethra;  to  pass  these  obstacles  the  beak  should 
be  elevated  by  lowering  the  shaft,  and  in  the  case  of  prostatic  obstruc- 
tion, a  catheter  with  a  pronounced  S-shaped  curve  generally  will  enter 
the  bladder;  a  familiar  maneuver  which  aids  in  passing  by  a  prostatic 
obstruction  is  to  introduce  the  full-curved  gum-elastic  instrument  as 
far  as  it  will  go  and  then  to  withdraw  the  stilet  about  an  inch,  when  the 

^  As  to  a  lubricant:  ordinary  carbolized  vaselin  or  glycerin  suffices,  but  since  these 
materials,  when  frequently  used,  may  damage  the  texture  of  a  catheter,  some 
such  lubricant  as  the  following,  suggested  by  Gouley,  may  be  employed: 

Powdered  white  Castile  soap 1  ounce 

Mucilage  of  chondrus  crispus 3  ounces 

Formalin  (40  per  cent,  solution  formaldehyd) 10  minims 

Thymol 5  grains 

Oil  of  thyme 5  minims 

Alcohol 15  minims 

Heat  the  soap  and  water  and  stir  until  smooth.  Add  the  mucilage  (one  ounce  of 
chondrus  crispus  to  one  pint  of  water) ;  when  cool,  pour  in  the  formalin  and  then  the 
thymol  and  oil  of  thyme  mixed  with  the  alcohol.  Put  up  in  two  collapsible  tubes 
-and  sterilize. 


392 


GEXITO-UUIXAUY    ORGAN'S 


beak  of  the  catheter  springs  u])\vard  and  fonvard  and  enters  the  bladc^er. 
Catheters  must  be  made  scru})ulously  aseptic  before  their  use,  and  for 
this  purpose  boihng,  or  immersion  in  1  :  3000  corrosive  subhmate 
solution,  generally  suffices.     I  have  not  considered  here  in  detail  the 


Fig.  239. — Passing  the  male  sound  or  catheter  (Hyde  and  Montgomery). 

pathologic  conditions,  such  as  stricture,  which  may  produce  an  imper- 
meable urethra  causing  retention,  but  I  shall  speak  of  these  conditions 
under  appropriate  headings. 

Should  the  surgeon  be  unable  to  pass  a  catheter  into  the  bladder, 
he  may  find  it  necessary  to  puncture  that  organ.     This  operation  is 


Fig.  240. — Passing  the  male  sound  or  catheter  (Hyde  and  l\fontgomery). 

easy  if  properly  undertaken.  Remember  that  you  are  dealing  with  a 
distended  bladder  rising  well  above  the  pubes.  Such  a  bladder,  as  it 
rises,  carries  before  it  and  above  it  the  peritoneum,  so  that  there  is  left 
a  small  space,  from  one  to  three  inches  in  extent,  above  the  pubes, 


RETENTION    OF    URINE 


393 


where  the  bladder  is  uncovered  of  peritoneum.  The  surgeon  punctures 
through  this  space.  It  is  well  first  to  anesthetize  the  skin  in  this  region 
bv  injecting  a  few  drops  of  2  per  cent,  solution  of  cocain,  so  that  the 
operation  of  puncture  may  be  painless;  then,  with  a  four-inch  straight 


Fig.  241. — Passing  the  male  sound  or  catheter  (Hyde  and  Montgomery). 

or  shghtly  curved  trocar  and  cannula,  stab  quickly  into  the  bladder, 
hugging  the  pubic  symphysis.  Withdraw  the  trocar  and  allow  the 
urine  to  escape  through  the  cannula.  It  is  an  old  teaching  that  the  total 
amount  of  urine  should  not  be  withdrawn  all  at  once,  either  by  catheter 
or  cannula,  from  a  greatly  distended  bladder,  as  the  sudden  rehef  of 


Fig.  242. — Passing  the  male  sound  or  catheter  (Hyde  and  Montgomery). 

pressure  causes  a  great  engorgement  of  the  venous  plexus  about  the 
bladder,  with  frequent  hemorrhage  into  that  organ  and  occasional 
collapse.  The  urine  should  be  drawn  off  slowly,  about  one-half  at  a 
time,  that  the  veins  may  accommodate  themselves  to  the  condition  of 


394  GENITO-rUIXAUY    ORGANS 

altered  pressure.  Under  certain  circumstances,  that  is,  when  it  is 
obvious  that  a  recurrence  of  retention  may  follow  the  temporary  relief, 
it  will  seem  wise  to  the  surgeon  to  institute  pei-mancnt  drainage,  either 
by  fastening  a  catheter  into  the  urethra,  or  a  cannvda,  passed  above  the 
pubes,  into  the  bladder. 


Fig.  243. — Suprapubic  puncture  of  the  bladder. 

All  these  suggestions  deal  with  intricate  and  perplexing  problems 
difficult  of  satisfactory  elucidation  in  a  brief  writing.  In  order  to 
become  familiar  with  these  problems  and  their  solution  the  student  must 
serve  a  proper  apprenticeship  under  the  direction  of  an  expert. 

CYSTITIS 

Cystitis  is  a  constantly  present  feature  in  all  diseases  of  the  bladder, 
and  is  an  extremely  frequent  complication  of  other  genito-urinary 
disturbances.  One  often  feels  that  inflammation  of  the  bladder  is 
almost  the  commonest  form  of  mucous  membrane  inflammation.  We 
encounter  it  in.  connection  with  all  sorts  of  general  infections,  such  as 
typhoid  fever  or  pneumonia,  besides  which  it  is  due  to  local  causes. 
The  pathologist  describes  3  types  of  cystitis:  (1)  Superficial  cystitis;  (2) 
interstitial  cystitis;  (3)  productive  cystitis.  Clinirally,  the  most  fre- 
quent forms  observed  are— (1)  Gonorrheal  cystitis;  (2)  tuberculous 
cystitis;  (3)  the  cystitis  of  urethral  stricture;  (4)  calculus  cystitis;  (5) 


CYSTITIS  395 

cystitis  of  tumors;  (G)  cystitis  of  prostatic  origin;  (7)  cystitis  of  instru- 
mentation. 

It  is  impossible  often  to  determine  accurately  the  exact  clinical 
type  of  cystitis  with  which  one  has  to  deal,  but,  in  fact,  the  symptoms 
are  much  the  same  in  all,  for  the  disease  is  of  bacterial  origin  and 
bacteria  of  similar  character  are  present  in  all  types — the  bacteria  of 
suppuration,  colon  bacilli,  and,  more  rarely,  typhoid  bacilli  and  pneumo- 
cocci.  Some  authorities  still  maintain  that  exposure  to  cold  is  a  cause 
of  cystitis,  but  even  granting  this,  such  exposure  acts  merely  by  reduc- 
ing the  resisting  power  of  the  tissues,  so  that  organisms  more  easily 
find  lodgment  and  work  havoc. 

So  far  as  our  understanding  the  type  goes,  the  definitions^gonorrheal, 
tuberculous,  etc. — carry  their  own  explanation.  Gonorrheal  cystitis 
obviously  is  an  extension  of  a  gonorrheal  process  from  the  urethral 
mucosa.  Tuberculous  cystitis,  like  gonorrheal  cystitis,  is  secondary, 
as  a  rule — secondary  to  tuberculosis  of  the  kidneys,  the  prostate,  the 
seminal  vesicles,  or  the  epididymis.  Tuberculous  cystitis  generally 
runs  a  chronic  course. 

The  symptoms  of  tuberculous  cystitis  are  particularly  important, 
and  the  gravity  of  the  condition  is  great.  You  will  observe  increasing 
frequency  of  micturition,  especially  during  the  day,  but  later  at  night 
as  well.  There  are  often  penile  pain,  bladder  tenesmus,  and,  sometimes, 
a  shutting  off  of  the  stream,  with  great  distress.  All  these  symptoms 
are  wont  to  grow  steadily  worse  in  spite  of  the  ordinary  methods  of 
treatment.  Indeed,  the  drug,  urotropin,  commonl}-  useful  in  other  forms 
of  cystitis,  seems  to  work  positive  damage  in  tuberculous  cases.  The 
diagnosis  of  tuberculous  cystitis  is  made  certain  by  finding  tubercle 
bacilli  (to  be  distinguished  from  smegma  bacilli)  in  the  urinary  deposit. 
Sometimes  it  is  necessary  to  examine  with  the  cystoscope,  when  the 
bladder  mucosa  will  show  at  first  infiltrated  areas  and  ecchymoses, 
and  later  numerous  circular  ulcers. 

The  cystitis  due  to  urethral  stricture  needs  no  special  explanation, 
nor  does  the  cystitis  of  calculus,  except  to  remark  that  when  a  stone 
forms  in  the  bladder,  the  formation  follows  a  cystitis,  while  a  bladder 
calculus  of  kidney  origin  precedes  and  causes  the  cystitis. 

Tumors  and  prostatic  enlargements  are  wont  to  obstruct  the  outflow 
of  urine,  and  to  damage  more  or  less  seriously  the  bladder-wall,  changing 
its  stmcture  and  tone  and  so  favoring  the  lodgment  and  development 
of  bacteria. 

An  extremely  common  cause  of  cystitis  is  instrumentation — the 
introduction  into  the  bladder  of  infective  organisms  on  catheters, 
sounds,  and  other  instruments.  It  is  difficult  to  prevent  such  infections, 
for  a  carefully  cleaned  catheter  may  pick  up  organisms  from  the  vulva 
and  urethra.  Obviously,  and  for  this  reason,  these  parts  should  be 
cleaned,  so  far  as  possible,  by  bathing  and  by  boric-acid  irrigations. 

The  S5anptom  which  always  suggests  cystitis  is  frequency  of  mic- 
1  urition ;  then  comes  pain,  during  and  after  the  act  of  micturition  (ten- 
esmus, the  painful  contraction  of  the  bladder  sphincter,  with  straining 


396  GENITO-UiaXARY   ORGAN'S 

and  a  sense  of  continued  desire  for  micturition) ;  pus  is  usually  found  in 
the  urine;  rarely  there  is  bloody  urine  (hematuria).  The  increased 
frequency  and  the  pain  are  constant  factors,  and  these  symptoms  are 
greatest  when  the  patient  is  upright  and  moving  about.  Observe  that 
frequency  due  to  prostatic  enlargement  is  greatest  during  the  night. 

The  inflamed  mucosa  is  extremely  sensitive  to  irritation,  whereas 
the  mucosa  of  the  normal  bladder  is  surprisingly  tolerant.  It  is  for  the 
former  reason  that  frequcnc}-  arises,  and  the  irritation  is  so  pronounced 
that  even  after  the  passage  of  urine  desire  and  tenesmus  persist  for 
some  minutes.  Early  in  the  disease  the  urine  may  be  acid  when  passed, 
but  upon  standing  its  contained  bacteria  multiply  and  alkalinity  fol- 
lows. Late  the  urine  when  passed  is  alkaline  and  is  loaded  with  pus 
and  bacteria.  In  acute  cystitis,  accordingly,  we  see  these  symptoms  and 
signs :  frequency,  pain,  and  pus.  Later,  the  disease  may  become  chronic. 
The  superficial  inflammation  gives  place  to  the  interstitial  inflamma- 
tion. The  bladder  becomes  more  or  less  thickened  and  permanently 
contracted.  Sacculation  or  the  formation  of  pockets  may  occur. 
The  symptoms  are  then  less  urgent,  though  still  constant.  The  dim- 
inished bladder  must  be  emptied  frequently;  the  tenesmus  is  less,  but 
there  is  superadded  a  sense  of  burning  and  weight  in  the  perineum; 
occasionally  blood  is  passed,  and  the  urine  will  be  found  to  contain  not 
only  pus  and  bacteria,  but  ropy  mucus,  which  settles  in  the  urine  glass 
and  clings  to  the  side  of  the  vessel.  Any  albumin  which  may  be  present 
is  due  to  the  blood  or  concurrent  renal  disease,  and  is  not  due  to  the  pus. 

The  picture  presented  b\'  patients  suffering  from  cystitis  is  distress- 
ing. They  are  wretched,  constantly  uneasy,  in  pain,  with  appetite 
diminished,  sleep  interrupted,  and  general  health  rapidly  breaking 
down. 

Fortunately,  the  treatment  of  C3'stitis  is  effective  in  most  cases, 
except  in  tuberculous  patients  and  in  those  suffering  from  concurrent 
ulceration  of  the  bladder.  From  what  I  have  said  it  is  obv-ious  that  the 
causes  and  complications  of  cystitis,  as  well  as  the  disea.se  it.self ,  must 
be  considered  and  treated.  Gonorrhea,  stone,  stricture,  must  severally 
be  dealt  with.  Setting  aside  for  the  moment  a  consideration  of  the 
underlying  causes  of  cystitis,  we  may  regard  those  mea.sures  which 
relieve  the  symptoms  and  may  be  looked  to  for  a  cure  of  cy.stitis  when 
uncomplicated. 

For  the  pain  and  frequency  opium  is  the  best  di-ug,  and  ordinarily 
it  should  be  given  by  the  rectum,  in  1-grain  suppositories.  Hot  ap- 
plications over  the  pubes  are  an  additional  comfort,  as  is  also  immersion 
in  a  hot  bath,  when  urine  may  be  passed  in  the  bath  with  little  distress. 
The  bowels  should  be  kept  open  by  salines  and  enemata,  and  the  diet 
should  be  limited  to  milk,  if  the  patient  will  bear  it.  In  chronic  cases 
one  should  allow  a  somewhat  more  liberal  diet.  At  the  same  time  cer- 
tain diuretics  are  u.'jeful ;  best  of  all,  urotropin.  in  T^-grain  do.ses,  with 
plenty  of  water,  eveiy  four  to  six  hours.  When  the  patient  can  bear  it, 
irrigations  of  the  bladder  are  useful  in  order  to  wash  out  the  pus  and 
mucus.      Frequently   it   is   necessary    to    cocainize   first    the   urethra. 


CYSTITIS 


397 


Ordinarily,  there  is  no  better  irrigating  fluid  than  a  4  per  cent,  boric- 
acid  sokition,  which  should  be  injected  reasonably  hot,  the  injections 
being  repeated  until  the  solution  returns  clear.^  Sometimes  the  bladder 
will  not  tolerate  irrigation,  in  which  case  instillations  may  be  sub- 
stituted, a  few  drops  of  argyrol  (10  per  cent.)  being  introduced  with  a 
Keyes  syringe  gently  into  the  deep  urethra.  Occasionally,  in  extremely 
obstinate  cases  of  cystitis,  and  as  a  prehminary  to  more  radical  measures, 
it  is  well  to  institute  permanent  drainage  for  a  time.  Such  drainage  is 
for  chronic  and  not  for  acute  cystitis. 

Such  are  the  measures  generally  found  effective  in  the  treatment 
of  the  inflamed  urinary  bladder.  There  is  another  condition,  commonly 
called  irritable  bladder,  Avhich  must  always  be  distinguished  from  cys- 
titis. Irritable  bladder  is  a  general  and  indefinite  term.  It  is  common 
in  neurotic  women  who  complain  of  frequent  calls  to  urinate  and  of 
inability  to  suppress  a  sudden  gush  of  urine.  Sufferers  from  nephro- 
lithiasis and  gout  also  have  irritable  bladders— so  do  typhoid  patients 
or  any  persons  who  secrete  a  scanty,  concentrated  urine.  Such  tumors 
as  uterine  myomata  and  ovarian  cysts  irritate  the  bladder.  Irritable 
bladder  often  runs  into  that  condition  known  as  incontinence  of  urine, 
in  which,  for  some  cause,  the  bladder  suddenly  finds  itself  unable  to 
retain  its  contents.  As  Fowler  says,  "  in  the  true  sense  the  term  is 
applied  to  cases  in  which  the  urine  escapes  as  soon  as  it  reaches  the 
bladder."  These  are  the  cases  in  which  the  bladder  is  paralyzed. 
Every  surgeon  who  has  had  to  deal  with  cases  of  '■'  broken  back"'  is 
familiar  with  incontinence  of  urine.  We  see  then  that  urinary  incontin- 
ence may  be  due  to  serious  central  lesions,  or  it  may  be  due  to  some  habit 
neurosis.  Nocturnal  wetting  belongs  to  the  latter  class,  and  is  particu- 
larly common  in  little  boys. 

The  treatment  of  incontinence  depends  upon  the  cause,  and  the 
milder  cases  only  can  be  treated  directly.  Sometimes  wornen  who  are 
so  troubled  may  be  cured  by  a  stretching  of  the  urethral  sphincter,  while 
mental  suggestion  is  of  great  value,  especially  through  directing  the 
patient  to  prolong  the  intervals  between  micturitions.  Excessive 
acidity  of  the  urine  must  be  corrected  by  giving  such  alkaUs  as  po- 
tassium acetate;  while  phimosis,  balanitis,  stricture,  stone,  pin-worms, 
and  overheating  with  a  multitude  of  blankets  must  be  met  by  appro- 
priate operations  and  suitable  hygienic  directions.  Sometimes,  for  the 
nocturnal  incontinence  of  children,  benefit  is  found  through  elevation 
of  the  pelvis  during  sleep  and  giving  increasing  doses  of  tmcture  of 
belladonna  until  the  physiologic  limit  is  reached.  In  the  case  of  adults, 
belladonna  plus  strychnin  (gr.  4V  to  t'o)  helps.  Incontinence  yields 
slowly  to  treatment  at  the  best,  and  I  have  known  cases  which  recov- 
ered after  long-continued  change  of  residence  or  a  distant  sea-vogage 
only. 

1  This  description  applies  to  non-tuberculous  cystitis  of  the  male  bladder.  The 
treatment  of  such  cystitis  in  the  female  bladder  is  still  more  simple  and  ettective. 
See  Edgar  Garceau,  Treatment  of  Tubercular  and  Non-tubercular  Cystitis  m  the 
Female,  Amer.  Jour.  Obstet.,  1907,  vol.  Ivi,  No.  3. 


398  GENITO-UHINAUY    ORGANS 

STONE  IN   THE  BLADDER 

Stone  in  the  bladder  seems  to  be  less  common  in  this  country  and 
at  the  present  day  than  as  described  by  former  writers.  In  some  parts 
of  the  world  it  is  still  frequently  encountered,  especially  among  eastern 
peoples,  among  whom  operators  for  stone  find  a  large  practice.  The 
removal  of  stone  is  one  of  the  most  ancient  of  surgical  operations. 
It  is  mentioned  in  the  oath  of  Hippocrates,  who  protests  that  he  will 
not  himself  perform  the  operation,  but  will  leave  it  to  those  whose  proper 
business  it  is. 

We  count  as  stone  proper  those  vesical  concretions  which  the  bladder 
cannot  expel  through  the  urethra.  These  stones  are  usually  made  up 
of  either  uric  acid  and  its  salts,  of  oxalate  of  lime,  or  of  phosphates  or 
carbonates,  sometimes  combined  with  urate  of  ammonia.  These  various 
groups  may  be  associated  in  the  structure  of  a  single  stone  or  the  stone 
may  contain  a  single  ingredient.  Moreover,  salts  may  be  deposited 
about  some  albuminous  substance,  or  some  foreign  body,  which  acts 
as  the  skeleton  or  nucleus  for  the  calcareous  collection. 

The  causes  of  stone  formation  are  various  and  sometimes  not  al- 
together obvious.  The  disease  is  thought  to  be  inherent  in  certain 
families,  while  diet  and  habit  are  factors  often.  Sundry  diseases  result- 
ing in  malnutrition,  such  as  gout  and  liver  diseases,  predispose  to  stone 
formation  of  the  uric-acid  type,  while  phosphatic  stones  are  the  result 
of  local  conditions,  such  as  alkaline  fermentation  of  the  urine  from 
chronic  cystitis,  or  retention  of  mine  from  any  cause — prostatic  en- 
largement, tumor,  stricture,  and  the  like.  Finally,  a  renal  stone 
discharged  into  the  bladder  may  lie  there  and  take  on  additional  de- 
posits. 

The  symptoms  of  stone  in  the  bladder  are  not  always  character- 
istic; they  may  be  extremely  puzzling,  and  they  may  suggest  some 
other  lesion.  The  old-time  questions  put  to  a  patient  were:  "  Do  you 
pass  blood  at  the  end  of  micturition?''  and  "  Does  driving  over  a  rough 
road  cause  pain  in  the  perineum?  "  A  positive  answer  to  these  questions 
is  suggestive  merely.  A  patient  may  carry  several  large  smooth  stones 
in  his  bladder  with  little  discomfort.  On  the  other  hand,  one  small 
rough  stone  may  cause  intolerable  agony,  especially  when  the  patient 
moves  about.  Such  a  stone  ma\'  have  come  down  from  the  kidney  with 
symptoms  of  renal  colic,  and  may  continue  to  cause  discomfort  and  pain 
after  it  reaches  the  bladder.  Stone  in  the  bladder  is  more  common  in 
males  than  in  females,  so  that  most  of  the  literature  on  the  subject 
deals  with  the  cases  of  men  and  boys.  Accordingly  the  pain  is  frequently 
referred  to  the  neighborhood  of  the  glans  penis,  a  little  behind  the  meatus 
and  below  it,  but  pain  is  not  invariable,  and  its  absence  does  not  prove 
the  absence  of  stone.  The  pain  is  due  commonly  to  contraction  of  the 
bladder  about  a  stone.  Sometimes  it  is  due  to  irritation  of  the  bladder 
mucosa  by  a  rough  stone.  Frequently,  cj'stitis  is  associated  with  stone, 
in  which  case  the  symptoms  of  cystitis  may  overshadow  the  symptoms 
of  calculus.     The  passage  of  a  few  drops  of  blood  at  the  end  of  mic- 


STONE    IN   THE   BLADDER  399 

turition  is  presumptive  evideiu-e  of  stone,  but  it  is  not  a  constant  sign. 
A  sudden  shutting  off  of  the  stream  during  micturition  sometimes  occurs 
and  is  due  to  a  stone's  falling  over  and  obstructing  the  internal  urethral 
opening.  In  men  with  enlarged  prostates  this  does  not  occur,  as  in 
such  persons  the  stone  ahvays  sinks  behind  the  prostate  to  the  bottom 
of  the  bladder. 

In  operating  within  the  bladder  for  conditions  other  than  stone, 
stones  previously  unsuspected  often  are  discovered,  for  the  presence  of 
such  calculi  is  masked  by  symptoms  of  cystitis,  by  bladder  tumors,  by 
prostatic  enlargements,  or  by  sacculations  within  which  the  stone  may 
lie  concealed. 

The  symptoms  of  stone,  however,  never  demonstrate  a  final  and 
positive  diagnosis.  The  surgeon  must  feel  and  hear  the  impact  of  a 
sound  upon  the  calculus;  and  if  this  does  not  suffice  to  clear  up  the  diag- 
nosis, he  must  inspect  the  bladder  through  the  cystoscope.  Sounding 
for  stone  is  sometimes  a  delicate  and  difficult  minor  operation,  not  care- 
lessly to  be  undertaken.  It  is  best  done  with  the  patient  lying  on  a 
harci  table.  As  a  first  step  one  should  thoroughly  wash  out  the  bladder 
with  boric-acid  solution,  and  should  leave  a  small  quantity  of  the  solu- 
tion in  the  bladder— 2  to  3  ounces  in  a  child,  8  to  12  ounces  in  a  man. 
The  patient's  hips  should  be  somewhat  elevated,  and  a  sHghtly  curved 
sound  or  stone-searcher  should  be  introduced  through  the  urethra, 
previously  cocainized.  It  is  a  needless  barbarity  to  search  for  stoiie 
without  having  given  some  anesthetic,  besides  which  the  anesthetic 
keeps  the  patient  quiet  and  makes  easier  the  surgeon's  work.  Usually 
the  stone,  if  present,  is  felt  lying  at  the  bottom  of  the  bladder,  a  httle 
below  the  internal  meatus.  Sometimes  an  elusive  stone  is  brought  to 
the  beak  of  the  searcher  by  a  finger  in  the  rectum,  elevating  the  bladder. 
Sometimes  the  stone,  overlaid  with  mucus,  escapes  entirely  the  exam- 
ining touch.  Sometimes  a  suspected  stone  is  discovered  by  w^ashing  the 
bladder  with  a  Bigelow  evacuator,  w^hen  a  sudden  checkmg  of  the  stream 
or  "  fish-bite,"  proclaims  the  presence  of  a  stone.  Kot  infrequently, 
a  second  or  third  examination  is  necessary  in  order  to  detect  the  stone, 
but  always  after  the  first  examination  it  is  well  to  employ  ether  anes- 
thesia, if  all  these  methods  fail  and  the  presence  of  stone  is  still 
strongly  suspected,  one  should  search  for  it  with  the  cystoscope. 

By  "^ whatever  method  a  stone  is  found,  its  size  should  be  deter- 
mined, either  bv  measuring  with  the  searcher,  or,  roughly,  by  visual 
cystoscopic  inspection.  Should  aU  other  methods  fail  and  stone  or  other 
serious  bladder  lesion  still  be  suspected,  the  surgeon  may  be  justified 
in  exploring  the  bladder  through  a  suprapubic  cystotomy. 

In  the  case  of  thin  women  and  in  yoimg  children  it  is  often  possible 
to  palpate  a  stone  bimanually,  with  one  finger  in  the  vagina  or  rectum 
and  a  hand  above  the  pubes. 

The  treatment  of  stone  in  the  bladder  is  a  subject  older  than  his- 
torv,  as  I  have  intimated,  and  from  the  earfiest  times  even  fairly  rational 
methods  of  extracting  calculi  have  maintained.  Obviously,  a  simple 
and  straightfoi-ward  manner  of  opening  the  bladder  is  the  old  one  of 


400  GEXITO-IRINARY    ORGANS 

passing  a  staff,  or  sound.  tlii()U<:li  tlic  urethra  and  cutting  upon  it,  by 
the  perineal  route,  until  the  hhukler  is  opened.  That  was  anci(!nt  prac- 
tice. In  more  modern  times  the  bladder  was  oj^ened  by  the  lateral 
perineal  route,  a  method  still  employed  occasionally.  Another  ancient 
practice,  popularized  in  recent  years,  is  suprapubic  opening  of  the  bladder, 
while  a  fourth  method,  in  great  vogue  during  the  past  thirty-five  years, 
is  to  crush  the  stone  within   the  bladder  by  instruments  introduced 


Fig.  244. — Litholapaxy;   crushing  the  stone  (diagrammatic). 

through  the  urethra,  and  to  wash  out  the  fragments.     This  last  procedure 
is  known  as  litholapaxy. 

Litholapaxy. — Jean  Civiale,  in  1824,  was  the  first  successfully  to  per- 
form the  operation  of  crushing  a  stone. ^  He  did  not  wash  out  the  frag- 
ments but  left  the  patient  to  pass  them.     Many  experimenters  worked 

1  Lithotrity:  crushing  a  stone.  Litholapaxy:  lithotrity  followed  by  prompt 
removal  of  fragments  of  the  stone  through  a  tube,  by  suction. 


STONE    IN   THE    BLADDER 


401 


to  perfect  a  better  tcchnic,  until  Henry  J.  Bigelow,  in  the  last  quarter 
of  the  nineteenth  century,  developed  the  modern  operation,  crushing 
and  evacuating  at  a  single  sitting — litholapaxy.  For  the  general 
surgeon,  and  with  suitable  cases,  litholapaxy  is  the  operation  of  choice. 
The  tcchnic  of  this  procedure  was  graphically  described  by  Bigelow  in 
a  brilliant  series  of  articles  published  in  1878  and  subsequent  years. 
The  instruments  required  are  lithotrites  of  various  sizes,  and  an  evacuat- 


Fig.  245. — Diagram  showing  Bigelow's  evacuator  in  place. 


ing  apparatus,  such  as  is  pictured  in  the  text.  Patients  wdth  im- 
permeable stricture,  with  extremely  hard  calculi,  wdth  encysted  stone,  or 
with  great  prostatic  enlargement,  are  not  fit  subjects  for  litholapaxy. 
In  no  case  should  the  operation  be  performed  hastily.  The  patient 
should  be  kept  in  bed  for  five  or  six  days  previously,  on  a  limited  diet, 
with  abundant  drinking  of  water  and  of  milk,  and  any  existing  cystitis 
should  be  treated  by  urotropin  and  irrigation.  Indeed,  litholapaxy 
should  not  be  undertaken  in  the  face  of  an  active  cystitis.     On  the 

26 


402  GENITO-URIXARY    ORGANS 

operating  table  the  patient  should  be  tipped  u])  in  a  modified  Trendelen- 
burg position,  the  urethra  and  bladder  should  be  thoroughly  irrigated, 
while  6  or  S  ounces  of  boric-acid  solution  (4  per  cent.)  should  be 
left  in  the  bladder.  We  are  now  ready  for  the  actual  crushing.  The 
surgeon  introduces  a  lithotrite,  of  the  Bigelow  or  Forbes  pattern,  letting 
it  glide  gently  into  the  urethra  and  passing  the  prostate  without  force. 
When  the  instrument  is  in  the  bladder,  the  handle  should  be  depressed 
to  an  angle  of  about  30  degrees  with  the  table,  and  with  the  beak  up- 
ward, the  instrument  should  be  made  to  he  at  the  bottom  of  the  bladder. 
The  jaws  are  opened  by  pulling  back  the  male  blade.  The  surgeon  waits 
for  a  moment  until  all  currents  have  subsided,  when  the  stone  usually 
will  be  found  to  have  fallen  between  the  blades.  It  is  then  seized  and 
crushed  and  the  larger  fragments  are  crushed  again  in  turn  until  the 
whole  mass  has  been  reduced  to  gravel.  After  that  the  lithotrite  is 
withdrawn,  when  the  surgeon  introduces  the  evacuating  tube  and  washes 
out  the  fragments.  This  part  of  the  operation  must  be  performed 
carefully  and  thoroughly,  so  that  no  fragments  be  left  to  form  the 
nucleus  of  a  new  stone.  Throughout  the  operation,  especially  when 
using  the  lithotrite,  the  surgeon  should  make  all  movements  care- 
fully and  gently,  taking  pains  especially  not  to  cru.sh  the  stone  until  it 
is  firmly  grasped  and  not  to  pinch  the  bladder-wall  within  the  jaws  of 
the  instrument. 

The  after-treatment  is  usually  simple,  and  amounts  to  little  more  than 
keeping  the  patient  in  bed  for  a  week,  administering  morphin  for  the 
early  pain,  and  giving  a  light  diet,  with  plenty  of  water.  If  retention, 
fever,  or  cystitis  supervene,  they  must  be  met  by  such  appropriate 
measures  as  catheterization,  the  administration  of  quinin  and  mor- 
phin, and  daily  irrigations  of  the  bladder.  The  mortality  from  lithol- 
apaxy  in  proper  cases  is  low,  and  even  in  children  it  is  the  best  opera- 
tion for  routine  practice. 

Suprapubic  cystotomy  for  stone  is  frequently  employed.  It  is 
indicated  in  the  cases  of  urethral  stricture,  of  great  prostatic  enlarge- 
ment, and  of  hard  and  multiple  stones,  as  well  as  when  stones  are  en- 
cysted and  inaccessible  to  the  lithotrite.  The  preparation  is  similar 
to  that  for  litholapaxy,  and  the  operation  is  facilitated  by  elevating  the 
patient  to  45  degrees  in  the  Trendelenburg  position,  and  introducing 
a  distensible  bag  or  colpeurynter  (with  which  some  surgeons  prefer  to 
dispense)  into  the  rectum,  in  order  to  elevate  the  bladder  above  the 
pubes.  From  4  to  8  ounces  of  boric-acid  solution  are  then  injected  into 
the  bladder  to  raise  it  further,  so  as  to  simplify  the  dissection  and  to  roll 
back  the  peritoneum.  Recollect  that  an  anterior  fold  of  the  peritoneum 
falls  over  the  collapsed  bladder,  while  a  full  bladder  pushes  the  peri- 
toneum upward  and  out  of  the  way.  I  recommend  a  transverse  in- 
cision at  the  upper  edge  of  the  pubes  through  the  skin  and  aponeurosis, 
as  I  have  found  that  such  an  incision,  when  healed,  gives  a  sense  of 
perfect  support  to  the  abdominal  wall,  AA'hen  the  surgeon  has  dissected 
well  back  and  separately  the  skin  and  aponeurosis,  he  splits  the  space 
between  the  pyramidales  muscles  and  enters  at  cnce  into  the  prevesical 


STONE    IN    THE    BLADDER  403 

space.  Sometimes  it  is  necessary  to  cut  away  from  the  pubes  the  muscle 
attachments.  There  is  no  excuse  for  blundering  into  the  peritoneal 
cavity.  Upon  opening  the  prevesical  space,  dissect  bluntly  with  the 
fingers  down  behind  the  pubic  arch  and  distinguish  the  outline  of  the 
bladder;  then  explore  it  by  pushing  back  the  fat,  and  seize  the  bladder- 
wall  with  forceps  or  tenacula.  Draw  up  the  bladder,  fix  it  firmly  in  the 
wound  with  tw^o  provisional  stitches,  one  on  either  side  of  the  median 
line,  and  held  by  an  assistant.  Then  open  the  bladder,  dissecting  back 
the  muscularis  from  the  mucosa,  and  opening  separately  each  layer. 
The  bladder  should  previously  have  been  packed  off  with  gauze  pads 
from  the  surrounding  tissues.     Evacuate  the  contained  fluid,  open  the 


Fig.  246.— Suprapubic  bladder  drainage. 

viscus  w^idely  with  retractors,  and  inspect  its  anterior  by  the  aid  of  a 
head-mirror  and  reflected  light.  Frequently  gauze  sponging  with  mops 
or  sweeps  may  be  necessary.  It  is  now  an  easy  matter  to  remove  calculi 
with  stone  forceps  or  the  fingers,  and  to  perform  any  further  operation 
which  may  be  indicated. 

The  after-treatment  of  the  woimd  is  somewhat  in  debate.  I  prefer  to 
leave  in  a  tubular  rubber  drain  after  sewing  up  the  bladder-wall  in 
layers  with  plain  catgut  stitches.  I  believe  strongly  in  the  use  of  a 
firmly  drawn  continuous  stitch  and  not  in  interrupted  stitches.  The 
stitches  may  penetrate  the  mucosa,  and  should  be  so  placed  in  a  double 
row  as  deeply  to  turn  in  the  bladder-wall.  The  rubber  tube,  and  a 
gauze  wack  draining  the  prevesical  space,  should  be  led  out  through  a 


404  GEXITO-URIXARY    ORGANS 

stab-wound  in  the  superior  skin-aponeurosis  flap,  well  away  from  the 
line  of  incision,  thus  favoring  a  rapid  and  aseptic  healing  of  the  orig- 
inal wound.  I  make  a  practice  furthermore  of  tying  into  the  blad- 
der through  the  urethra  a  soft  catheter,  to  insure  constant  drainage. 
If  all  goes  well,  the  suprapubic  gauze  drain  is  removed  at  the  end  of 
three  days,  and  the  suprapubic  iiibber  drain  at  the  end  of  eight  days. 
The  resulting  wound  heals  shortly,  but  the  urcthi-al  drain  is  kept  in 
place  four  or  five  days  after  the  removal  of  the  suprapubic  drain. 

No  further  after-treatment  is  indicated  except  in  the  case  of  com- 
plications, especially  cystitis,  which  can  be  cared  for  readily  by  through- 
and-through  irrigation  from  above. 

The  mortality  after  suprapubic  cystotomy  for  stone  is  slightly 
higher  than  after  litholapaxy,  but  I  doubt  if  this  is  due  to  any  disad- 
vantage inherent  in  the  operation  itself.  The  true  cause  probably  lies 
in  the  fact  that  we  do  the  operation  of  litholapaxy  in  the  simpler  ca.ses. 
The  true  disadvantage  in  cystotomy  is  the  longer  convalescence — three  or 
four  weeks — which  it  entails. 

In  this  place  it  does  not  seem  necessarj'  to  describe  at  length  the 
various  operations  of  perineal  lithotomy.  They  are  little  practised 
to-day  as  compared  with  the  operations  already  described.  As  I  have 
stated,  the  principle  of  these  perineal  operations  is  the  cutting  into  the 
bladder,  either  laterally  or  mesially,  upon  a  staff,  through  the  prostate. 
The  operations  in  themselves  are  not  particularly  difficult,  but  they 
involve  more  or  less  groping  in  the  dark,  and  the  not  infrequent  danger 
of  permanent  damage  to  the  ejaculatory  seminal  ducts.  I  refer  the 
student  to  the  text-books  on  operative  surgery  should  he  wish  to  study 
the  methods  of  perineal  lithotomy. 

In  women  stone  in  the  bladder  is  less  common  than  in  men,  and  is 
far  more  easily  treated.  Small  stones  may  be  removed  through  the 
urethra  by  dilating  that  passage,  seizing  the  stone  in  forceps,  and  ex- 
tracting it;  or  litholapaxy  easily  maybe  performed,  or  suprapubic  cys- 
totomy. I  do  not  advise  opening  the  bladder  through  the  vagina,  be- 
cause that  operation  occasionally  has  been  followed  by  a  permanent 
vesicovaginal  fistula. 

In  connection  with  the  subject  of  cystitis  and  stone  I  must  call  the 
reader's  attention  to  ulcer  of  the  bladder. 

ULCER  OF   THE  BLADDER 

This  affection  is  not  especially  uncommon,  and  is  seen  more  frequently 
in  women  than  in  men.  There  are  two  leading  forms  of  ulcer,  the  tuber- 
culous and  that  caused  by  erosion  from  long-continued  irritation  by 
stone  or  cystitis.  There  are  also  the  small  multiple  erosions  similar  to 
gastric  erosions  in  appearance. 

These  bladder  ulcers  may  cause  little  trouble,  or  they  may  give  rise 
to  the  most  distressing  symptoms,  such  as  constant  pain  and  tenesmus, 
especially  after  micturition.  Sometimes  blood  is  passed  mingled  with 
the  urine,  and  there  may  be  general  constitutional  disturbances. 


TUMORS   OF   THE   BLADDER  405 

The  treatment  of  tubercvilous  ulceration  is  systemic  and  topical. 
I  have  not  been  able  to  convince  myself  that  without  general  treatment 
local  treatment  is  et^ective;  but  certain  it  is  that  the  open-air  life  and 
improved  hj-giene  often  work  remarkable  cures. 

The  diagnosis  of  ulcer  of  the  bladder  can  bo  confirmed  by  the  cys- 
toscope  only,  when  areas,  sloughing  or  granulating,  usually  bleeding, 
and  sharply  defined  from  the  surrounding  mucosa,  appear.  The  char- 
acter of  the  urine  is  not  pathognomonic,  but  suggests  a  cystitis  merely. 

The  treatment  of  bladder  ulcer  in  addition  to  the  general  hygienic 
course  already  suggested,  consists  in  local  applications  through  the  end- 
oscope, and  the  drug  commonly  employed  is  some  one  of  the  silver  salts. 
In  the  case  of  non-tuberculous  ulceration  I  have  often  seen  rapid  im- 
provement and  cure  by  touching  the  base  of  the  ulcer  with  a  10  per 
cent,  silver  nitrate  solution,  and  sometimes  by  the  pure  caustic  even, 
though  the  latter  may  cause  great  subsequent  pain.  At  the  same 
time  patients  should  be  put  upon  a  bland  diet,  mainly  milk  and  water, 
and  should  be  given  urotropin,  7^  grains  every  six  hours.  The  same 
local  treatment  is  of  some  value  in  the  case  of  tuberculous  ulcers. 
Furthermore,  the  injection  of  iodoform  suspended  in  olive  oil  is  valuable 
— one  dram  of  iodoform  to  one  ounce  of  pure  olive  oil,  a  dram  of  this 
mixture  being  left  in  the  bladder  once  daily. 

TUMORS   OF   THE   BLADDER 

Tumors  of  the  bladder  are  among  the  rarer  diseases  of  that  organ,  but 
are  extremely  interesting  from  the  therapeutic  as  well  as  from  the 
pathologic  point  of  view.  Often  they  cause  distressing  symptoms;  they 
can  be  removed  with  difficulty  only  and  they  have  a  high  mortality. 
Watson  ^  states  that  in  the  case  of  benign  tumors  of  the  bladder  even, 
including  myxoma,  the  operative  mortality  is  17  per  cent.,  while  the 
operative  mortality  of  cancer  is  27  per  cent.,  and  that  of  sarcoma,  63 
per  cent. ;  from  which  it  will  be  seen  that  many  varieties  of  tumor  occur 
in  the  bladder,  and  that  it  is  dangerous  to  remove  them.  From  the 
recent  studies  of  Davis  ^  it  appears  that  calculus  does  not  predispose  the 
bladder  to  tumor. 

All  tumors  of  the  bladder  have  a  peculiar  and  interesting  structure — 
whether  benign  or  malignant,  they  tend  to  assume  a  polypoid  character. 
This  is  probably  due  to  the  fact  that  they  spring  from  a  contractile  base, 
constantly  varying  in  size  and  position.  There  are  the  benign  tumors, 
papillomata,  single  and  multiple,  mostly  pedunculated,  generally  cauli- 
flower in  appearance,  with  a  circumscribed  base  and  little  tendency  to 
involve  deepty  the  bladder-wall.  A  connective-tissue  form  of  this 
growth  sometimes  undergoes  transformation  into  sarcoma.  Further- 
more, there  are  fibrous  polypi  and  myxomata,  the  former  being  true 
pedunculated  fibromata  ancl  myxomata,  being   generally   single    and 

1  F.  S.  Watson,  The  Operative  Treatment  of  Tumors  of  the  Bladder,  Ann.  Surg., 
December,  190.5. 

-  Lincoln  Davis,  Primary  Tumors  of  the  Urinary  Bladder,  ibid.,  April,  1906. 


406  GENITO-l'HlXARY    ()U(;ANS 

resembling  nasal  polypi.     Then  there  are  niyomata,  generally  single, 
partially  pedunculated,  and  attaining  the  size  of  a  small  orange  even. 

Of  the  malignant  tumors,  sarcoma  is  exti-emely  rare,  but  carcinoma  is 
more  frequent;  it  is  a  common  bladder  tumor.  Observe  that  carcinoma 
may  develo])  out  of  pai)illoma;  that  primary  carcinoma  in  its  early 
stages  resembles  papillonui  grossly,  but  that  (juickly  it  involves  deeply 
the  bladder-wall.  Carcinoma  is  found  most  frequently  springing  from 
the  trigonum,  the  prostate,  or  the  urethral  orifices,  while  the  non-malig- 
nant forms  of  tumor  are  found  anywhere  upon  the  bladder-wall.  Ob- 
viously, cancer  of  the  bladder  may  be  secondary,  extending  from  cancer 
of  the  rectum  and  other  organs,  or  rarely  it  may  be  metastatic.  \\'atson's 
studies  show  that  myxomata,  which  occur  generally  in  young  children, 
have  a  high  mortality  and  recur  quickly  after  operation.^ 

The  symptoms  of  tumor  of  the  bladder  may  be  characteristic  or  they 
may  be  extremely  confusing,  and  especially  ai-e  they  to  be  distinguished 
from  the  symptoms  of  stone,  of  ulcer,  and  of  enlarged  prostate.  In  the 
case  of  all  tumors  of  the  bladder  the  commonest  symptoms  are  hemoj- 
rhage,  frequency,  and  pain.  Hemorrhage,  without  other  symptoms, 
especially  is  to  be  observed.  Whether  the  tumor  be  benign  or  malig- 
nant, it  may  give  rise  to  the  symptom  of  hemorrhage  only,  for  many 
months  or  years — hemorrhage  coming  at  the  end  of  micturition  often, 
sometimes  abundant.  Often  extreme  clotting  takes  place,  filling  the 
bladder,  so  that  the  patient  suffers  from  retention  of  urine  and  tenesmus. 
There  may  result  a  hydronephrosis  or  pyonephrosis.  Moreover,  there 
is  often  an  associated  cystitis,  which  adds  to  the  misery  of  the  sufferer, 
but  the  cystitis  does  not  occur  early  in  the  disease.  And  cystitis  is  the 
cause  of  pain,  except  in  the  case  of  cancer.  Observe,  then,  that  in  differ- 
entiating benign  from  malignant  tumors  of  the  bladder  we  find  both 
associated  with  hemorrhage,  while  the  cystitis  and  pain  are  late  in  the 
case  of  benign  disease,  but  are  relatively  early  in  the  case  of  cancer. 
Indeed,  in  the  case  of  cancer,  pain  precedes  or  accompanies  the  first 
appearance  of  blood. 

In  making  the  diagnosis  of  bladder  tumor  we  have  to  difTerentiate 
between  that  condition  and  renal  disease  associated  with  hemorrhage, 
bladder-stone,  tuberculosis,  and  prostatic  enlargement.  In  tumor, 
the  hemorrhage  is  usually  constant  and  abundant;  sometimes  it  is  in- 
termittent; in  prostatic  enlargement  the  frequency  of  micturition  is 
increased  at  night;  in  stone,  pain  is  aggravated  by  exercise.  Analysis 
of  the  urine  helps  in  the  diagnosis  of  tumor,  for  frequently  particles  of 
the  neoplasm  may  be  discovered  in  the  urinary  sediment.  Through 
bimanual  examination  the  indurated  base  of  a  cancer  may  be  detected 
by  the  finger  in  the  rectum,  though  benign  growths  may  thus  rarely  be 
demonstrated;  and  observe  in  this  connection  that  bladder  tumors  are 
somewhat  more  common  in  men  than  in  women.     Moreover,  according 

1  The  following  revised  classification  is  that  of  Davis: 

(Papilloma.  I  Sarcoma. 

Adeno^r*  ^-  Connective-tissue  group;  -j  pibroma!  ^-  Muscle  group:  Myoma. 
Cysts.  I  Angioma. 


TUMORS   OF   THE    BLADDER  407 

to  sex,  visual  inspection  with  tlio  cystoscope  is  facilitated,  and  in  women 
digital  touch  through  the  urethra  is  made  possible.  Finally,  in  the 
case  of  tumor,  as  of  stone,  a  suprapubic  cystotomy  may  be  necessary 
to  ascertain  the  true  condition. 

A  notable  fact  about  tumors  of  the  bladder,  whether  benign  or  malig- 
nant, is  that,  if  not  removed,  eventually  they  kill  the  victim.  In  the 
case  of  a  benign  tumor,  he  dies  of  hemorrhage,  or  renal  involvement 
through  obstruction  to  the  ureters,  with  hydronephrosis  or  pyonephro- 
sis. In  the  case  of  a  malignant  tumor  he  dies  a  lingering  death  from 
extensive  disease  of  the  genito-urinary  organs  and  from  metastases — 
and,  be  it  observed,  that  metastases  appear  late  in  the  course  of  bladder 
cancer — sometimes  not  until  the  fourth  or  fifth  year  of  the  disease. 

It  is  obvious,  therefore,  that  energetic  treatment  is  necessary,  and 
extirpation  of  the  growth  is  the  only  successful  treatment.  The  field 
is  relatively  a  new  one.  Either  suprapubic  cystotomy  or  transperiton- 
eal cystotomy  w^ith  excision  of  the  growth  is  imperative  in  all  cases. 
If  the  disease  be  benign,  and,  therefore,  superficial,  the  margin  of  the 
dissection  need  not  be  wide  so  long  as  an  uninvolved  portion  of  the 
bladder-wall  be  removed  with  the  tumor.  Such  an  operation  is  not 
particularly  dangerous,  and  gives  a  reasonable  chance  of  permanent 
cure.  The  rent  in  the  bladder-wall  at  the  site  of  the  tumor  should  be 
carefully  repaired  with  a  plain  catgut  suture,  which  will  be  softened 
and  absorbed,  or  expelled,  before  it  can  become  the  nucleus  of  calculus. 
In  the  case  of  benign  recurrence  even  a  secondary  operation  may  be 
followed  by  permanent  cure. 

The  question  of  what  operation  to  perform  in  the  case  of  bladder 
cancer  or  sarcoma  is  not  so  easily  answered.  Should  the  growth  be  ex- 
tensive and  involve  other  organs,  nothing  more  than  curetage  and  cauter- 
ization is  proper.  By  such  means  hemorrhage  is  checked  for  a  time, 
and  considerable  relief  is  afforded.  But  in  the  earlier  cases  there  is 
reason  to  hope  that  we  may  secure  by  excision  longer  immunity  or  a 
permanent  cure,  and  with  these  cancers,  as  with  all  others,  we  should 
operate  early.  Indeed,  bearing  in  mind  the  possibility  of  a  benign 
bladder  tumor's  suffering  malignant  changes,  the  surgeon  should 
insist  always  upon  an  early,  radical  operation  for  all  bladder  tumors. 
Hitherto,  surgeons  have  contented  themselves  with  resecting  broadly 
the  bladder-wall  for  cancer,  opening  from  above  through  a  liberal  in- 
cision, and  freeing  the  bladder  thoroughly,  so  far  as  may  be,  on  all  sides 
of  the  growth.  Sometimes  it  is  well  to  provide  a  supplementary  ap- 
proach through  the  perineum,  and  I  shall  have  a  word  to  say  on  this 
matter  when  discussing  cancer  of  the  prostate.  After  removing  the 
growth  the  bladder-wall  is  to  be  sewed  up  in  layers,  pains  being  taken 
not  to  damage  the  ureters.  In  this  connection  it  is  interesting  to  con- 
sider the  important  radical  suggestion  of  Watson,^  "  that  total  extir- 
pation of  the  bladder  and  of  the  prostate,  if  it  be  involved  in  the  patho- 
logic process,  be  done  at  the  outset  in  all  cases  of  carcinoma  that  have 
not  extended  beyond  the  limits  of  the  above-named  structures,  and  in 

1  See  footnote  on  p.  406. 


408  GENITO- URINARY   ORGANS 

which  it  is  believed  that  there  are  no  metastases;  and  that  the  same 
measure  shall  be  applied  in  all  cases  of  benign  growths  in  which  recurrence 
has  taken  place  after  a  primary  operation  for  their  removal." 

Watson  would  provide  for  kidney  drainage  by  bilateral  nc))hrostomy, 
after  extirpation  of  the  bladder,  as  he  is  convinced  that  this  is  a  measure 
less  dangerous  to  renal  structure  than  is  implantation  of  the  ureters  in 
the  bowel  or  in  the  skin.  He  asserts  that  the  condition  of  the  patient 
after  neplirostomy  can  be  made  tolerable  by  the  wearing  of  a  proper 
receptacle  for  the  collection  of  urine.  I  am  not  aware  of  any  general 
resort  to  Watson's  operation,  but  it  seems  probable  that  it  offers  the 
best  chance  of  life  for  the  patient  should  he  survive  the  operation. 
Watson  does  not  advocate  bladder  removal  and  nephrostomy  at  one 
sitting,  but  would  perform  primary  nephrostomies  on  the  first  and  second 
kidneys,  with  an  interval  of  a  month  between,  and  would  extirpate  the 
bladder  some  weeks  later.  He  would  tie  off  the  ureters  both  from  above 
and  from  below. 

Since  1893  the  transperitoneal  or  intraperitoneal  cystotomy  of  F.  B. 
Harrington  ^  has  been  gaining  in  popularit}-,  and  is  now  in  common  use, 
I  find,  in  many  American  clinics.  The  technic  of  this  operation  is  simple: 
the  abdomen  is  opened  widely  above  the  pubes;  the  intestines  walled 
back;  the  bladder  exposed  and  opened  freely  through  the  peritoneum. 
This  opening  gives  an  extremely  wide  and  easy  approach  to  the  bladder 
tumors,  which  may  then  be  excised  with  a  knife  or  the  Paquelin  cauter3^ 
The  bladder  is  closed  in  three  layers  with  interiiipted  catgut  stitches. 

I  have  employed  with  satisfaction  a  modification  of  Harrington's 
method;  after  the  abdomen  is  opened  and  the  bladder  exposed,  I  have 
turned  down  a  flap  of  peritoneum  in  the  shape  of  an  inverted  U  from 
the  posterior  surface  of  the  bladder  and  have  then  opened  the  bladder- 
wall  through  a  longitudinal  incision  beneath  the  flap  of  peritoneum. 
As  a  result  of  this  maneuver  the  bladder  wound,  when  sewed  up,  becomes 
an  extraperitoneal  wound. 

In  broad  terms,  it  appears  that  the  methods  of  treatment  are  still 
5w6  judice,  and  Davis'  interesting  conclusions  are  worth  quoting: 

"  Surgical  intervention  at  the  proper  time  in  the  case  of  peduncu- 
lated papillary  tumors  of  the  bladder  offers  a  very  fair  chance  of  long 
immunity,  if  not  of  permanent  cure. 

"  The  method  of  surgical  intervention  to  be  proposed  in  these  cases 
is  excision  of  the  tumor  in  toto,  with  a  margin  of  bladder-wall  at  its  base, 
including  mucosa,  submucosa,  and  muscularis  in  part:  the  section  need 
not  penetrate  the  entire  thickness  of  the  wall." 

SACCULATION  OF  THE  BLADDER 

Sacculations  of  the  bladder  are  coming  to  be  regarded  as  something 
more  than  surgical  curiosities,  or  conditions  suited  to  palliative  treat- 
ment merely.     Bladder  sacculations  are  quite  similar  in  stmcturc  to  the 

1  Charles  L.  Scudder  and  Lincoln  Davis,  Harrington's  Operation  of  Intraperi- 
toneal Cystotomy,  Ann.  Surg.,  December,  1908. 


BLADDER    INJURIES  409 

diverticula  found  in  the  colon.  They  are  either  true  sacculations  of  the 
whole  thickness  of  the  bladder-wall,  or,  more  commonly,  they  are  hernia 
of  the  mucosa.  If  the  sacculations  are  large  and  saucer-shaped,  they 
give  little  trouble.  Often,  however,  they  are  almost  polypoid  in  shape — 
their  lumina  being  of  considerable  size,  while  the  entrance  from  the 
bladder  into  the  sacculations  is  small. 

The  symptoms  of  sacculation  are  often  extremel}-  distressing.  In  it 
there  becomes  established  chronic  inflammation  with  constant  pus- 
formation,  which  is  persistently  forced  out  into  the  bladder.  Cystitis 
results;  stones  may  be  lodged  or  may  form  in  the  sacculation,  and  so  add 
to  the  patient's  misery.  In  general  terms,  therefore,  the  symptoms 
of  sacculation  of  the  bladder  are  the  symptoms  of  a  severe  chronic 
cystitis.  By  the  use  of  the  cystoscope  alone  can  the  sacculation  be  dis- 
covered and  the  diagnosis  established. 

The  treatment  is  difficult  and  unsatisfactory  often.  The  only  sure 
method  is  radical  and  severe — excision  of  the  sacculation.  Approach 
the  bladder  by  the  transperitoneal  route;  turn  down  a  flap  of  peritoneum; 
dissect  the  bladder  free  from  surrounding  structures,  especially  toward 
its  base;  develop  the  sacculation;  excise  it;  repair  the  rent  with  catgut 
stitches;  sew  up  the  peritoneal  flap,  with  a  drainage  wick  led  out  from 
beneath  the  flap  to  and  through  the  external  wound.  Institute  constant 
drainage  by  a  catheter  in  the  urethra.  If  the  patient  is  not  too  much 
exhausted  by  long  disease,  this  operation  should  restore  him  to  health 
in  from  three  to  four  weeks. 

Besides  the  bladder  lesions  already  described,  the  surgeon  must  be 
prepared  vigorously  to  treat  cases  of  injuries. 

BLADDER  INJURIES 

Injuries  to  the  bladder  are  conditions  extremely  familiar  to  every 
large  general  hospital.  These  injuries  may  be  intraperitoneal  or  ex- 
traperitoneal, and  the  intraperitoneal  injuries  are  three  times  the 
commoner.^  Up  to  twenty-five  years  ago,  intraperitoneal  ruptures  were 
held  to  be  fatal,  and  it  is  within  recent  times  only  that  we  have  been 
able  to  meet  and  remedy  successfully  this  alarming  lesion. 

The  condition  involves  rupture  of  all  the  coats  of  the  bladder  and  of 
the  peritoneum,  with  the  escape  of  urine  and  blood  into  the  peritoneal 
cavity,  and  the  symptoms  are  extremely  variable.  There  may  be  pro- 
found shock  from  the  outset,  or  there  may  be  Httle  disturbance  at  first. 
In  the  course  of  a  short  time,  however,  evidence  of  shock  appears — rapid 
pulse,  collapse,  pallor,  and  cold  extremities.  There  is  nearly  always  an 
associated  hemorrhage,  and  shortly  a  general  peritonitis.  Peritonitis 
and  shock  are  the  common  causes  of  death,  while  death  from  hemorrhage 
is  rare.  Operative  treatment  for  intraperitoneal  rupture  is  imperative 
and  should  be  instant.  The  surgeon  opens  the  abdomen  in  the  median 
line,  tips  the  patient  into  the  Trendelenburg  position,  packs  back  the 

1  See  important  essay  on  this  subject  by  Daniel  Fiske  Jones,  Intraperitoneal 
Rupture  of  the  Bladder,  Ann.  Surg.,  February,  1903. 


410  GENITO-URINARY   ORGANS 

intestines,  finds  the  rent  in  the  bladder,  and  sews  it  up.  That  placing 
of  the  sutures  is  important.  Fine  catgut  is  the  best  material,  and  a  con- 
tinuous suture  here  is  superior  to  the  interrupted  suture,  the  catgut 
being  so  buried  in  the  bladder-wall  as  to  obviate  the  probability  of  stone 
formation.  There  should  be  three  rows  of  stitches — the  first  to  include 
the  mucosa,  submucosa,  and  muscularis,  the  second  and  third  to  repair 
the  peritoneal  rent  and  to  turn  in  the  line  of  incision.  The  abdominal 
wound  should  be  closed  with  gauze  drainage  (stab-wound),  and  an 
inlying  catheter  should  be  left  in  the  urethra.  If  symptoms  of  peri- 
tonitis exist  or  appear  later,  I  institute  the  method  of  rectal  injections 
described  in  Chapter  VIII  (proctoclysis) . 

Extraperitoneal  rupture  of  the  bladder  is  found  in  the  region  of 
the  bladder  base,  and  is  due  commonly  to  a  direct  crushing  force  which 
often  fractures  the  pelvis  and  urethra.  These  injuries  are  dangerous 
also,  but  less  fatal  than  the  intraperitoneal  ruptures.  The  shock  is 
less  profound,  though  hemorrhage  may  be  considerable,  while  peritonitis 
is  improbable.  Blood  finds  its  way  behind  the  peritoneum,  both  up- 
ward and  backward,  distending  with  hematoma  the  perineum  and 
the  abdominal  wall.  If  untreated,  this  blood  deposit,  mingled  with 
urine,  becomes  septic,  and  extensive  abscesses  ensue.  In  such  a  case 
recently,  when  in  doubt  as  to  the  exact  site  of  the  rupture,  I  opened  into 
a  great  bloody  cloaca  near  the  navel,  and  not  until  I  had  cleared  this  out 
and  found  the  source  of  bleeding  was  I  able  to  determine  that  the  peri- 
toneal cavity  was  uninvolved.  As  a  rule,  therefore,  these  subcutaneous 
collections  of  blood  indicate  extraperitoneal  rupture,  intraperitoneal 
rupture  affording  exit  for  blood  and  urine  directly  into  the  peritoneal 
cavity. 

In  making  the  diagnosis  of  ruptured  bladder  a  most  valuable  aid, 
and  one  resorted  to  as  a  routine,  is  catheterization.  If  rupture  exists, 
especially  if  an  hour  or  more  has  passed  since  the  patient  urinated,  the 
catheter  will  draw  nothing  but  a  little  pure  blood,  showing  that  the  con- 
tents of  the  bladder  have  escaped  inward.  Bloody  urine  in  any  consider- 
able amount  suggests  an  injury  to  the  kidneys,  or  possibly  a  mere  con- 
tusion of  the  bladder,  while  clear  urine  proves  the  urinaiy  apparatus  to 
be  undamaged. 

The  treatment  of  extraperitoneal  rupture  of  the  bladder  may  be  simple 
or  may  be  intricate.  Catheter  drainage  by  the  urethra  should  be  in- 
stituted, hematomata  should  be  opened  and  explored,  hemorrhage 
should  be  checked,  and,  if  possible,  the  bladder  rent  should  be  repaired. 
But  such  primary  repair  rarely  is  possible.  Generally,  one  can  do  no 
more  at  the  first  than  evacuate  the  bloody  collections  and  drain  per- 
manently the  bladder,  waiting  for  nature  to  act  either  in  establishing 
a  cure  or  in  forming  a  urinary  fistula,  which  later  must  be  treated  by 
excision  and  suture.  At  the  same  time  damaged  pelvic  bones  must  be 
held  firmly  in  place  with  a  plaster  swathe. 

Gunshot  wound  is  a  rare  injury  to  the  bladder.  When  the  peri- 
toneal cavity  is  opened  by  a  bullet,  there  result  sj^mptoms  similar  to 
those  already  described  as  due  to  ruptured  bladder,  and  median  abdomi- 


ANATOMY   OF   THE    PROSTATE  411 

nal  section  is  necessary.  If  the  wound  be  extraperitoneal,  the  condition 
is  not  so  grave,  especially  since  the  track  of  the  bullet  affords  some  degree 
of  drainage  for  the  urine.  Otherwise  the  treatmerit  is  much  the  same  as 
in  the  case  of  rupture  of  the  bladder. 

Foreign  bodies  in  the  bladder  are  strangely  frequent,  and  are  found 
in  women  especially.  The  significance  of  foreign  bodies  in  the  bladder  is 
that  they  act  as  calculi,  and  generally  become  nuclei  for  stone  forma- 
tion. Sexual  perverts  find  strange  instruments  to  use  in  assaulting  their 
own  bladders.  Sometimes  women  introduce  foreign  bodies  into  their 
bladders  when  attempting  to  produce  abortion,  for  the  large  female 
urethra  gives  a  ready  access  to  the  bladder.  Hospital  museums  show 
curious  collections  of  these  foreign  bodies  removed  from  the  bladders 
of  both  sexes — hat-pins,  hair-pins,  shoe-strings,  coins,  thimbles,  wire- 
nails,  and  so  on  in  great  variety.  They  may  be  removed  with  forceps 
and  endoscope,  by  litholapaxy,  or  by  suprapubic  cystotomy. 

Thus  it  will  be  seen  that  the  bladder  is  an  organ  subject  to  a  variety 
of  diseases,  intimately  associated  in  its  disease  processes  with  the  kidney 
and  ureter,  and  fairly  accessible  to  instrumentation.  It  will  now  be  in- 
teresting to  study  the  common  diseases  of  that  important  appendage  to 
the  bladder — 

The  Prostate 

General  interest  in  the  surgery  of  the  prostate  is  in  marked  contrast 
to  interest  in  bladder  surgery,  if  one  may  judge  from  a  perusal  of 
current  literature.  I  find  in  my  files  of  the  last  four  years  48  essays  on 
prostatic  surgery  as  compared  with  6  essays  on  bladder  surgery.  But, 
doubtless,  with  the  settlement  of  debated  questions,  such  a  discrepancy 
will  disappear.  Although  surgeons  for  many  years  have  done  some 
little  work  on  prostatic  disease,  it  is  within  the  past  six  or  eight  years  only 
that  reasonably  safe  and  sure  relief  for  prostatic  enlargement  has  been 
found  through  the  development  of  an  ingenious  and  rational  operative 
technic.^  The  hypertrophied  prostate  especially  has  exercised  surgeons, 
but  there  are  other  prostatic  lesions  of  great,  though  minor,  interest, 
and  as  a  preliminary  to  a  brief  study  of  prostatic  disease  let  us,  in  a  few 
words,  consider  the  anatomy  of  the  prostate. 

ANATOMY  OF  THE  PROSTATE 

Observe  that  the  prostate  gland  lies  entirely  outside  of  the  bladder 
and  that  it  envelops  the  urethra.  It  does  not  lie  below  the  urethra, 
as  many  students  think.  The  urethra  passes  through  the  prostate. 
The  prostate  develops  in  the  same  manner  as  do  other  acinous  glands, 
and  grows  laterally  as  well  as  in  the  median  line.  So  we  find  formed  two 
main  lateral  lobes,  between  which  the  urethra  passes.  The  lobes  are 
connected  in  front  of  the  urethra  by  the  anterior  commissure,  and 
beneath  the  urethra  by  the  posterior  commissure.  The  lower  portion  of 
the  anterior  commissure  has  been  commonly  and  improperly  associated 

1  F.  S.  Watson,  The  Operative  Treatment  of  the  Hypertrophied  Prostate,  Ann. 
Surg.,  June,  1904. 


412  GENITO-URIXARY   ORGANS 

with  the  term,  "  middle  lobe."  The  glandular  tissue  is  intenvoven  with 
muscle  tissue,  the  muscle  tissue  being  arranged  specially  about  the  neck 
of  the  bladder,  forming  an  internal  and  external  sphincter,  while  the  20 
or  30  glandular  lobules  are  held  together  by  stout  bands  of  intenvoven 
fibrous  tissue  and  muscle-fibers,  which  make  up  the  capsule  also. 
Thus  we  have  entering  into  the  structure  of  the  prostate  three  distinct 
types  of  tissue, ^glandular,  fibrous,  and  muscle, — and  as  a  result  we 
shall  find,  as  we  should  expect,  that  these  three  types  enter  character- 
istically into  the  various  forms  of  prostatic  disease.  Moreover,  there 
are  certain  ducts,  crypts,  and  other  structures  associated  with  the  pros- 
tate. The  ejaculatory  ducts  pass  through  it,  and  it  contains  its  own 
prostatic  ducts,  as  well  as  the  urethral  canal.  The  gland  is  compared  in 
size  and  shape  with  an  Italian  chestnvit,  its  base  lying  against  the  bladder 
and  rectum,  its  apex  pointing  fonvard  under  the  pubes.  If  3'ou  split 
open  the  prostate  from  above  down  into  the  urethra,  you  expose  certain 
delicate  and  interesting  structures  on  the  floor  of  the  urethra — the 
prostatic  sinuses  or  gutters  on  either  side  of  the  verumontanum,  and  the 
sinus  pocularis  or  blind  canal,  tunneling  beneath  the  verumontanum; 
while  upon  or  within  its  margins  are  the  slit-like  openings  of  the  ejacu- 
latory ducts.  Though  the  prostate  lies  entirely  behind  the  triangular 
ligament,  its  strongest  attachments  are  to  the  posterior  surface  of  that 
ligament,  and  it  is  quite  firmly  bound  to  the  rectum  also.  The  prostate 
is  adherent  to  the  deeper  parts  of  the  prostatic  urethra,  behind  the  veru- 
montanum, and  this  fact  explains  the  difficulty  of  removing  the  whole 
prostate  without  removing  a  considerable  portion  of  the  prostatic 
urethra.  Furthermore,  the  whole  gland  is  enveloped  in  a  stout  capsule, 
which  is  smooth  over  the  lateral  lobes,  but  is  intimately  connected 
with  the  gland  in  the  median  line,  about  the  numerous  vessels  which  are 
located  there.  The  seminal  vesicles  lie  entirely  behind  the  prostate  on 
the  bladder-wall.  Their  ducts  enter  the  prostate  from  below  and  pass 
through  it  together,  close  to  the  median  line,  until  they  empty  into  the 
urethra.  On  this  anatomic  fact  Young  ^  has  founded  his  proposition  of 
removing  prostatic  lobes  through  lateral  incisions  into  the  gland,  so  as 
to  avoid  injuring  the  vessels  and  the  ejaculatory  ducts. 

So  much  for  the  anatomy  of  this  organ,  which  has  been  abundantly 
studied  and  copiously  illustrated  by  recent  writers. 

We  may  conveniently  group  diseases  of  the  prostate  under  the 
headings  inflammations,  hypertrcphy ,  and  tumors,  though  it  may  be 
proper  to  regard  hypertrophies  as  either  inflammations  or  tumors. 

INFLAMMATIONS   OF  THE   PROSTATE 

Inflammations  of  the  prostate  are  acute  and  chronic,  but  we  usually 
mean  acute  inflammation  when  we  speak  of  prostatic  inflammation. 
Acute  inflammation  of  the  prostate  assumes  the  forms  common  to  all 
glandular  inflammations.  Ordinarily  in  acute  prostatitis  there  is  an 
invasion  by  organisms  of  the  ducts  from  without — from  the  urethra. 

1  Hugh  H.  Young,  Jour.  Amer.  Med.  Assoc,  October  24,  1903. 


INFLAMMATION    OF  THE    PROSTATE 


413 


Swelling,  desquamation,  necrosis,  and  suppuration  supervene,  the 
usual  attendant  efforts  of  nature  to  arrest  the  invasion.  The  gonococ- 
cus  and  other  pus-producing  cocci  are  the  ordinary  invading  organisms, 
while  rarely  the  organisms  of  tuberculosis  and  syphilis  may  be  implanted 
here.  The  patient  experiences  a  sense  of  weight,  heat,  and  pain  in  the 
perineum.  Often  there  are  frequency  of  micturition  and  tenesmus 
from  involvement  of  the  bladder.  There  may  be  great  prostration  and 
a  general  constitutional  disturbance.  Frequently  the  onset  of  the  attack 
comes  with  a  chill.  The  abscess  may  open  into  the  urethra,  rectum,  or 
bladder,  or  into  the  peritoneal  cavity  even,  through  burrowing  upward. 
Either  the  parenchyma  of  the  prostate  or  the  muscular  tissue  or  both 
may  be  involved.  Sometimes  there  is  urinary  obstruction,  and  in 
extreme  cases  the  process  may  go  on  to  destruction  of  neighboring 


Fig.  247. — Massaging  the  prostate. 
Sketch  showing  position  of  hand  and 
forearm. 


Fig.  248. — Sketch  showing  relative  posi- 
tion of  surgeon  and  patient. 


parts  through  gangrene,  to  peritonitis,  phlebitis,  thrombosis,  and  py- 
emia. Occasionally  acute  symptoms  gradually  may  subside,  leaving 
behind  a  chronic  process  which  is  marked  by  a  general  thickening  and 
enlargement  of  the  prostate,  associated  with  a  cord-like  thickening  of 
the  vesicles  and  ducts,  and  in  some  cases  by  a  well-defined  abscess. 
The  most  important  symptom  of  chronic  prostatitis  is  a  discharge  from 
the  urethra  of  a  milky  fluid,  in  greater  or  less  quantity,  especially  after 
defecation,  followed  by  pain  in  the  course  of  the  urethra. 

The  reader  will  probably  conclude  that  the  treatment  of  prostatitis 
varies  with  varying  forms  of  the  disease.  In  acute  prostatitis  one  en- 
joins absolute  rest,  thorough  evacuation  of  the  bowels,  urotropin,  and 
the  application  of  either  heat  or  cold  to  the  perineum  and  hypogastrium. 
Sometimes  constant  cold  rectal  irrigations  are  a  great  comfort.  If  an 
abscess  develops,  it  must  be  opened,  preferably  through  the  perineum 


414  OENITO-URINARY   ORGANS 

or  urethra.  If  the  prostatitis  is  gonorrheal,  local  urethral  treatment 
must  be  abandoned  temporarily  or  until  the  prostatic  complication  sub- 
sides. Burrowing  pus  and  complicating  infections  must  be  treated  by 
appropriate  dissections.  Chronic  prostatitis  is  a  difficult  subject  for 
treatment.  It  yields  slowly,  if  at  all,  though  sundry  well-recognized 
remedies  should  be  used  and  may  be  helpful.  If  gonorrhea  or  stricture 
is  present,  it  must  be  cured,  because  it  may  be  keeping  up  the 
prostatic  irritation.  Cold  applications  by  rectal  irrigation  are  com- 
forting, lodin  in  some  form  is  valuable,  and  may  be  applied  by  m- 
unction  to  the  perineum,  or,  mixed  with  an  ointment,  it  may  be 
passed  on  a  sound  into  the  deep  urethra.  Most  important  of  all, 
prostatic  massage  is  extremely  helpful.  The  seminal  vesicles  fre- 
quently are  involved  with  the  prostate,  and  massage  of  all  these 
organs,  by  the  finger  in  the  rectum,  should  be  practised  for  a  time,  at 
intervals  of  every  third  day.  Frequently  it  is  surprising  to  feel  the  in- 
duration subside  under  the  finger,  while  the  patient  will  return  after  the 
first  or  second  treatment  with  the  statement  that  he  is  greatly  relieved. 
Certain  enthusiasts  have  claimed  great  benefit  from  opening  the  vesicles 
and  prostate  through  the  rectum  or  through  the  perineum,  but  the  ex- 
perience of  others  suggests  that  this  is  a  difficult  remedy,  and  may  be 
dangerous.  The  value  of  prostatectomy  for  chronic  prostatitis  is  still 
sub  judice.  Patients  afflicted  with  infiammatoiy  prostatic  troubles  are 
apt  to  become  wretched  ''  neurasthenics,"  as  the  phrase  is,  and  their 
general  health  should  be  looked  to  carefully,  with  tonics,  mineral  baths, 
and  sanatorium  treatment. 

Tuberculous  prostatitis  usually  is  secondary,  almost  never  primary, 
and  its  treatment  should  be  symptomatic,  as  a  rule — an  out-of-doors 
life.  If  an  abscess  has  formed,  it  may  be  opened,  and  the  prostate  cur- 
etted or  enucleated  through  a  perineal  incision  without  opening  the 
rectum.  Unfortunately,  these  cases,  as  a  rule,  go  on  to  a  general  tuber- 
culosis. 

PROSTATIC  CALCULI 

Prostatic  calculi  deserve  mention,  though  they  are  relatively  rare 
and  may  well  be  confounded  with  bladder  calculi.  They  are  generally 
phosphatic,  and  may  be  multiple,  collecting  in  the  prostatic  sinuses. 
The  symptoms  simulate  closely  those  of  stone  in  the  bladder,  and  the 
positive  diagnosis  often  is  difficult.  Prostatic  stones  may  be  detected 
protruding  into  the  urethra,  by  the  examining  finger  in  the  rectum, 
w^hile  a  sound  in  the  urethra  supports  the  prostate.  Those  calculi  which 
protrude  into  the  urethra  may  be  picked  out  with  long  urethral  for- 
ceps, while  the  larger  and  more  deeply  placed  stones  can  be  extracted 
by  perineal  section.  These  prostatic  calculi,  like  gall-stones,  are  to 
be  regarded  as  of  inflammatory  origin,  their  nuclei  being  generally  the 
desquamated  cells  resulting  from  some  previous  infection. 

By  far  the  most  interesting  disease  of  the  prostate,  however,  and  one 
which  many  are  coming  to  believe  represents  in  an  extreme  degree  the 
results  of  long-standing  inflammation,  is  hypertrophy  of  the  prostate. 


HYPERTROPHY    OF   THE    PROSTATE  415 

HYPERTROPHY  OF  THE  PROSTATE 

Benign  enlargement  of  the  prostate  is  commonly  called  hypertro'phy 
of  the  prostate,  .-^.bout  this  disease  debate  still  centers.  What  is  its 
cause?  How  shall  it  be  treated?  Briefly,  let  us  consider  these  questions, 
as  well  as  the  questions  of  symptoms  and  diagnosis. 

Statistics  seem  to  show  that  30  per  cent,  of  men  over  fifty  have  some 
degree  of  enlargement  of  the  prostate.  Fortunately,  as  in  the  case 
of  gall-stone  victims,  the  lesion  produces  serious  symptoms  in  a  relatively 
small  proportion  of  persons.  It  is  rare  to  hear  of  prostatic  disturbances 
in  a  man  under  forty-five,  and  it  is  still  rarer  that  the  initial  symptoms  of 
enlarged  prostate  appear  after  seventy.  There  is  excellent  reason  for 
believing,  however,  that  frequently  the  prostatic  disease  begins  much 
earlier  than  the  forty-fifth  year.  The  question  of  etiology  has  given 
rise  to  an  interesting  discussion,  as  yet  unsettled,  but  the  studies  of 
Finger,  Ciechanowski,  Crandon,^  and  others  are  so  thorough,  and  their 
findings  so  convincing,  that  I  believe  we  are  justified  in  concluding  a 
majority  of  these  enlarged  prostates  to  be  of  inflammatory  origin. 
Crandon  draws  the  following  conclusions: 

"  (1)  The  underlying  cause  of  the  usual  form  of  prostatic  enlargement 
and  of  certain  forms  of  prostatic  atrophy  is  a  slow  formation  of  new  con- 
nective tissue,  due  to  infection  or  to  infection  aggravating  a  senile  degen- 
erative process. 

"  (2)  The  gonococcus  is  probably  most  often  the  specific  infection  (?) 
because^ (a)  of  its  great  frequency;  (6)  other  inflammatory^  causes  are 
not  common  in  the  parts  in  question;  (c)  a  great  similarity  exists  be- 
tween the  histology  of  gonorrheal  processes  and  those  seen  in  these  senile 
prostates. 

"  (3)  Neoplasms,  fibromyomata,  and  adenoma  occur,  but  may  be 
called  rare." 

Numerous  other  writers,  from  Morgagni  and  John  Hunter  do\\Ti  to 
those  of  our  o-^ti  time,  have  held  varying  views  of  the  etiology,  assert- 
ing that  these  enlargements  are  due  to  inflammations,  to  new-growths, 
to  some  relation  betw^een  the  testes  and  the  prostate,  to  a  general  h^-per- 
trophy  of  prostatic  connective  tissue,  etc. ;  but  it  now  seems  probable, 
as  I  have  already  stated,  that  a  chronic  inflammation  of  the  glandular 
elements  is  the  most  important  element  in  the  etiology  of  prostatic 
hypertrophy.  Doubtless,  myomata  and  other  new-growths  occasion- 
ally play  a  part,  while  Young  finds  that  prostatic  cancer  is  found  in 
about  14  per  cent,  of  those  persons  who  come  under  surgical  treatment 
for  prostatic  enlargements. 

The  size  and  the  shape  of  enlarged  prostates  vary,  though  the  largest 
prostate  is  not  likely  to  be  more  than  four  or  five  ounces  in  weight. 
The  enlarged  prostate  may  be  spongy,  or  may  increase  in  consistencj'  up 
to  a  hard  fibrous  resistance,  and  there  may  be  variation  also  of  consist- 
ency in  different  parts  of  the  gland.     One  lateral  lobe  only  may  be  en- 

1  L.  R.  G.  Crandon,  The  Pathogenesis  and  Pathologic  Anatomy  of  Enlarged 
Prostate,  Ann.  Surg.,  December,  1902.  For  an  interesting  resume  of  opposing  views 
see  article  by  Paul  Si.  Pilcher,  Ann.  Surg.,  1905. 


41G 


GENITO-URINAKY    ORGANS 


largcd,  or  there  may  occur  the  formation  of  a  middle  lobe.  This  last 
is  an  interesting  condition.  Formerly  it  was  held  that  the  middle  lobe 
arises  from  the  posterior  portion  of  the  isthmus,  but  later  and  more  care- 
ful observations  demonstrate  that  the  poly})oid  middle  lobe  has  nothing 
to  do  with  the  isthmus.  The  middle  lobe  tlevclops  from  a  few,  isolated, 
prostatic  acini,  which  lie  between  the  vesical  nmcosa  and  the  internal 
urethral  sphincter.  The  middle  lobe  alone  may  be  enlarged  or  it  may 
be  associated  with  enlargement  of  the  other  lobes.  The  most  common 
form  of  enlargement  is  the  bilateral  form,  and  after  that  a  uniform 
enlargement  of  the  whole  gland,  including  the  middle  lol)e. 

The  student  will  observe,  therefore,  that  enlargement  of  the  prostate 
may  or  may  not  give  rise  to  distortion  or  obstruction  of  the  urethra, 


Fig.  249. — Suprapubic  prostatectomy.  Sagittal  section  of  pelvis,  show-ing 
finger  enucleating  the  prostate  from  its  sheath  as  counterpressure  is  made  i)y  the 
other  hand  in  the  rectum  Shows  also  tortuous  course  of  urethra  througli  enlarged 
prostate. 

according  as  the  forms  of  the  enlargement  vary.  An  overdevelop- 
ment of  one  lobe  will  push  the  urethra  to  one  side;  an  overdevelop- 
ment of  both  lobes  will  elongate  the  prostatic  urethra.  An  upward 
protrusion  of  the  prostate  into  the  bladder  will  elevate  and  throw  for- 
ward the  internal  urethral  orifice,  or  there  may  result  an  actual  bar 
formation  at  the  neck  of  the  bladder.  The  reader  will  observe  also  that 
the  enlarged  prostate  may  project  as  a  whole  beneath  the  bladder 
mucosa,  rendering  the  tumor  easily  accessible  from  above;  or  the  growth 
may  project  toward  the  rectum  only,  rendering  the  mass  easily  accessible 
from  below.  All  these  variations  in  size  and  shape  may  puzzle  the  stu- 
dent, but  he  should  study  the  formations  on  the  cadaver  and  in  plates. 

The  syynptoms  of  enlarged  prostate  should  be  obvious  to  the  reader 
who  is  familiar  with  diseases  of  the  bladder,  for  the  prostate,  when  en- 


HYPERTROPHY  OF  THE  PROSTATE 


417 


largcd,  becomes  essentially  a  tumor  of  the  bladder-wall,  while  necessarily 
it  involves  the  urethra  at  the  same  time.  Therefore,  the  first  and  most 
characteristic  symptom  of  enlarged  prostate  is  J'requcncy  of  micturition; 
and  note  this  characteristic  fact,  that  the  frequency  is  most  pronounced 
at  night,  and  is  due  to  a  congestion  of  the  bladder  and  prostate.  Next 
the  patient  notices  difficulty  in  passing  water,  so  that  the  act  is  accomp- 
lished with  straining  and  more  or  less  pain.  The  difficulty  increases 
with  time,  until  the  flow  comes  drop  by  drop.  This  difficulty  is  due  to 
the  tortuous  course  into  which  the  urethra  has  been  forced  by  the 
enlarging  prostate,   and  to  the  consequent  elevation  of  the  internal 


Fig.  250. — General  prostatic  enlargement  with  the  formation  of  a  median  over- 
growth and  posterior  pocket  or  sac.  Illustrating  how  residual  urine  may  be 
retained,  as  well  as  the  difficulties  of  all  kinds  of  instrumentation  (Socin  and  Burck- 
hardt). 


meatus  toward  the  front  of  the  bladder-wall,  where  a  valve-like  opening 
is  formed,  which  excessive  straining  closes.  As  the  enlarged  prostate 
encroaches  upon  the  urethra  within  it,  it  throws  the  lower  posterior  part 
of  the  bladder  into  a  cup-like  fold,  depressed  beneath  and  behind  the 
internal  meatus.  As  a  result,  urine  which  cannot  be  evacuated  collects 
in  this  pocket — so-called  ''  residual  urine,"  that  which  remains  after 
the  patient  has  evacuated  all  that  he  can  (Fig.  250).  With  such  con- 
ditions present  one  maj^  easily  picture  the  complications  and  results 
of  prostatic  enlargement.  An  underlying  gonorrhea,  exposure  to  cold 
and  wet,  some  slight  injury,  or  some  intercurrent  illness  may  be  the 

27 


418  GEXITO-UKIXARY    ORGANS 

immediate  cause  of  an  acute  infection,  when  there  follow  increased 
swelling  of  the  gland,  invasion  of  the  bladder  by  septic  organisms, 
cystitis  with  decomposition  of  the  residual  urine,  increased  frequency, 
pain,  and  further  wretchedness. 

The  progress  of  prostatic  hypertrophy  so  called  is  by  no  means  uni- 
form. A  majority  of  the  victims  of  prostatic  hypertrophy  live  for  many 
years  wdth  but  slight  difficulty.  Their  troubles  are  not  constant,  for 
their  attacks  come  and  go  with  varying  frequency.  Generally,  they  can 
be  kept  comfortable  with  care  in  the  diet,  regulation  of  the  bowels,  and 
a  more  or  less  quiet  life.  On  the  other  hand,  certain  cases  progress 
rapidly  to  complications.  The  prostate  enlarges,  the  obstruction  be- 
comes more  pronounced,  inflammation  is  quite  constant,  residual  urine 
increases  in  amount,  the  bladder  becomes  chronically  inflamed,  thick- 
ened, and  sacculated,  and  finally  the  infection  extends  to  the  ureters  and 
kidneys,  so  that  the  patient  succumbs  eventually  to  a  pronounced 
general  infection.  Many  of  the  patients  are  sufferers  from  arteriosclero- 
sis and  heart  complications;  their  condition  is  anything  but  favorable, 
either  for  prolonged  life  or  for  operation. 

One  cannot  lay  down  definite  rules  of  treatment ;  each  case  must  be 
handled  on  its  own  merits;  for  some,  an  early  operation  may  seem  best; 
for  others,  palliative  treatment,  in  the  hope  that  an  operation  msiy  be 
avoided.  Palliative  treatment  is  extremely  serviceable,  and  consists 
in  the  proper  use  of  the  catheter.  The  surgeon,  so  soon  as  he  is  convinced 
that  "  frequency"  exists  and  that  it  is  associated  with  more  or  less  pain, 
should  pass  a  soft  catheter  into  the  bladder  and  determine  whether  or  not 
there  be  residual  urine  present.  Usually,  he  will  find  it  there,  and  if  so, 
he  should  instruct  the  patient  to  empty  the  bladder  with  the  catheter 
frequently  enough  to  secure  comfort.  Some  patients  require  catheteri- 
zation but  once  a  day,  preferably  in  the  evening.  Others  should  catheter- 
ize  themselves  twice  a  day,  others  more  often;  but  I  doubt  if  it  is  wise 
ever  to  encourage  a  patient  to  use  a  catheter  more  than  five  or  six  times 
in  the  twenty-four  hours. 

The  type  of  catheter  to  be  used  is  all  important.  If  the  disease  be 
not  pronounced,  if  the  prostate  be  small,  and  the  passage  fairly  patent, 
the  patient  may  use  a  No.  10  or  12  EngHsh  soft-rubber  catheter, 
which  will  easily  enter  the  bladder.  My  preference  is  to  limit  patients 
to  this  type  of  catheter.  I  never  feel  safe  in  allowing  them  the  use  of 
stiff  or  sharply  curved  instruments,  so  that  I  have  formulated  this  rule: 
if  the  patient  can  pass  comfortably  and  safely  a  soft-rubber  catheter, 
I  allow  him  to  do  so,  but  no  more  than  four  times  in  the  twenty-four 
hours.  If  more  frequent  catheterization  is  necessary,  I  take  the  matter 
out  of  the  patient's  hands  and  catheterize  him  myself,  or  advise  a  rad- 
ical operation.  The  question  of  what  catheter  the  surgeon  himself 
shall  use  to  enter  the  patient's  bladder  has  provoked  needless  discus- 
sion: if  I  cannot  pass  the  soft-rubber  catheter,  then  my  preference  is 
for  the  gum-elastic  English  web.  No.  10  or  12,  armed  with  a  stilet. 
When  this  is  properly  curved  in  an  S  shape,  it  may  generally  be 
passed  into  the  bladder  without   difficulty.     Hey's  old   maneuver  of 


HYPERTROPHV    OF    THE    I'KO.STATE 


419 


passing  it  as  far  as  possible,  and  then  withdrawing  the  stilct  about  an 
inch  so  as  to  allow  the  beak  of  the  catheter  to  jump  forward  and  upward, 
is  extremely  useful  still.  There  are  the  familiar  instruments  with  curved 
angles,  those  of  Mercier,  of  LeRoy,  and  of  Guthrie.  In  an  emergency,  if 
the  patient's  bladder  is  full,  if  the  catheter  cannot  be  passed,  and  if 
relief  must  be  secured  at  once,  the  bladder  may  be  aspirated  above  the 
pubes— an  easy  operation  and  painless  if  a  little  2  per  cent,  cocain  has 
been  injected  under  the  skin  previously. 

In  the  use  of  catheters  absolute  cleanliness  must  be  secured,  and  the 
utmost  gentleness  must  be  employed.     In  these  patients  the  prostatic 
urethra  is  twisted  and  occasionally  sacculated,  so  that  any  considerable 
force  may  cause  the  beak  of  the  cath- 
eter to  pass  into  the  prostate  gland 
itself.     False  passages  thus  are  formed, 
which  become  infected,  and  the  misery 
of   the    patient   shortly  becomes    ex- 
treme. 

If  catheterization  is  impossible,  if 
aspiration  above  the  pubes  alone  re- 
mains, and  if  operation  is  contraindi- 
cated  by  the  poor  general  condition  of 
the  patient,  constant  drainage  above 
the  pubes  may  be  secured  by  leav- 
ing the  cannula  of  the  aspirator  in 
place.  After  a  few  days  the  cannula 
may  be  withdrawn  and  a  small  cath- 
eter inserted.  This  drainage,  which 
has  been  established  with  little  or  no  shock  to  the  patient,  acts 
kindly  upon  an  inflamed  prostate,  relieving  it  of  pressure,  subduing 
congestion,  and  frequently  bringing  about  the  state  of  affairs  which 
permits  of  the  subsequent  passage  of  a  catheter  by  the  natural  route. 
If  the  patient's  strength  remains  good,  but  the  reestablishment  of 
urethral  drainage  is  impossible,  and  a  radical  operation  is  too  dangerous, 
it  may  seem  well  to  the  surgeon  to  establish  permanently  suprapubic 
drainage.  This  can  be  done  with  slight  shock  to  the  patient,  and  is  a 
relatively  easy  operation.  (It  is  accompHshed  essentially  by  the  method 
I  described  when  speaking  of  stone  in  the  bladder — by  suprapubic 
cystotomy  or,  in  this  case,  cystostomy.)  The  bladder  is  brought  up  into 
the  external  wound,  its  wall  is  opened,  and  the  catheter  is  inserted  by 
the  Witzel  method  or  by  that  of  Gibson.  The  catheter  may  be  worn 
permanently,  or  may  be  withdrawn  after  ten  days  and  the  resulting 
sinus  may  be  utilized  for  the  passage  of  urine.  A  fairly  competent 
stoma  frequently  results,  so  that  the  patient  can  retain  a  considerable 
amount  of  urine  in  the  bladder,  and  then,  by  straining  or  pressing  above 
the  pubes,  can  empty  the  bladder  without  a  catheter.  The  reader 
should  not  be  confused,  however,  or  led  to  suppose  that  this  is  a  common 
outcome  of  the  catheter  life.  Permanent  drainage  by  suprapubic 
cystostomy  rarely  is  necessary. 


Fig.  251. — Diagram  showing  cath- 
eter placed  for  bladder  drainage. 


420  GENITO-l'IMNARY   ORGANS 

Let  US  now  briefly  consider  methods  of  dealing  directly  with  the 
gland  itself — removing  it  or  tunneling  a  pro))er  passage  through  it. 
The  prostate  may  b(;  drilled  through  by  the  instrument  of  Jiottini,  or 
may  be  removed  entire,  either  fiom  above  (su])ra])ubic  prostatectomy) 
or  from  below  (perineal  j^rostatectomy).  That  operation  of  liottini  is 
interesting;  first  developed  by  him  in  1S74,  its  technic  has  been  greatly 
improved,  especially  by  the  author  himself  and  by  Freudenberg  and 
Young,  until  the  best  modern  instruments  have  assunujd  a  form  of 
efficiency  which  renders  them  accurate  and  effective.  General  anes- 
thesia is  not  necessary  for  their  use.  The  operation  is  frequently  per- 
formed with  the  employment  of  cocain  anesthesia  only.  Persons  un- 
familiar with  the  Bottini  operation  have  claimed  that  it  is  blind,  un- 
surgical,  and  dangerous;  but  the  elaborate  statistics  of  Watson  and 
others  show  that  the  Bottini  operation,  in  proper  hands,  is  effective,  and 
carries  with  it  a  low  mortality.  In  a  word,  the  instrument  is  a  galvano- 
cautery  which  burns  deep  grooves  in  the  projecting  prostatic  lobes, 
and  opens  a  free  passage  for  the  urine.  Before  employing  this  instru- 
ment it  is  imperative  that  the  surgeon  inspect  the  prostate  and  the 
bladder  with  the  cystoscope.  Without  such  visual  inspection  one  cannot 
determine  the  relations  of  the  enlarged  prostatic  lobes  to  each  other 
and  to  the  urethra,  but,  instructed  by  the  cystoscopic  inspection,  the 
surgeon  should  be  able  accurately  and  deftly  to  burn  the  required 
tunnel.  Young's  improved  instrument  generally  is  used  in  this  country. 
Its  advantage  is  that  it  has  a  variety  of  blades  enabling  the  surgeon  to 
enlarge  the  oj^ening  required  to  any  desired  extent.  Disinfect  the 
urine  with  urotropin  and  one  or  two  vesical  irrigations.  No  other  sub- 
sequent treatment  is  necessary.  These  patients  have  been  allowed 
to  go  about  after  forty-eight  hours  even,  but  such  radical  haste  is  not 
to  be  commended.  The  patients  generally  are  persons  of  advanced 
years,  with  an  enfeebled  cardiovascular  system,  and  should  be  kept 
quiet  until  the  immediate  ill-effects  of  the  operation  have  subsided. 
Enjoin  hot  sitz-baths,  a  milk  diet,  diuretics,  rest,  and  fresh  air.  In 
spite  of  the  advantages  of  Bottini's  operation,  I  cannot  agree  with  those 
writers  who  assert  that  it  is  always  the  operation  of  choice.  On  the 
contrary,  I  believe  that  it  is  often  the  operation  of  last  resort,  and  is 
to  be  employed  in  those  cases  only  which  cannot  be  submitted  to  the 
more  radical  operation  of  prostatectomy.  In  general  terms,  then,  the 
surgeon  should  reserve  the  Bottini  operation  for  those  patients  who 
are  so  enfeebled  that  one  dare  not  inflict  upon  them  a  prostatec- 
tomy. The  immediate  results  of  the  Bottini  operation  generally  are  good, 
but  the  end-results  are  not  always  satisfactory,  for  recurrence  of  the 
urethral  obstruction  not  infrequently  follows  after  an  interval  of  one  or 
two  years. 

Complete  'prostatectomy  or  radical  proslatcctortiy  is  a  subject  which  agi- 
tates operators  to-day,  and  it  has  done  so  for  the  past  ten  years.  \'ig- 
orous  exponents  of  the  suprapubic  and  of  the  perineal  routes  are  still  in 
conflict.  It  is  not  reasonable  that  such  conflicts  should  continue.  Any 
surgeon  familiar  with  both  operations  will  admit  that  each  has  its  place. 


HYPERTROPHY    OF   THE    PROSTATE 


421 


Those  enlarged  prostates  which  encroach  Uttle  upon  the  rectum  and 
perineum,  but  project  far  into  the  interior  of  the  bladder,  are  more 
easily  attacked  from  above  by  the  average  operator,  so  that  for  those 
cases  I  advocate  the  suprapubic  operation  except  for  the  expert.  It 
can  be  done  readily,  satisfactorily,  and  effectively,  and  the  results  are 
almost  always  good.  On  the  other  hand,  those  prostates  which  encroach 
upon  the  rectum  and  lie  almost  entirely  in  front  of  the  bladder  are  prop- 
erly and  easily  to  be  removed  by  the  perineal  route.  The  statistics 
of  "both  operations  vary,  and  the  weight  of  evidence  seems  to  show  that 
the  suprapubic  operation  is  somewhat  the  more  dangerous,  having  a 


Fi„  252.— Diaerammatic  drawing,  showng  above,  a  flap  of  mucous  membrane 
left  by^'shelling  out  a  prominent  third  lobe,  and  below,  a  remnant  ot  the  urethral 
mucous  membrane  extending  back  into  the  cavity  frorn  which  the  prostate  has  been 
removed— either  of  which  would  tend  to  form  a  valvular  closure  ot  the  urethra 
(Cabot). 

rather  higher  operative  mortality  rate.  One  questions  w^hether  this 
may  not  be  because  surgeons  have  failed  to  choose  their  method  judi- 
ciously, but  have  employed  the  suprapubic  route  for  cases  which  should 
have  been  operated  upon  by  the  perineal  route. 

Suprapubic  prostatectonnj  is  an  easy  operation,  as  a  mie.  ine 
bladder  should  be  fiUed  wdth  4  to  6  ounces  of  boric-acid  solution;  the 
patient  should  be  placed  in  a  mocUfied  Trendelenburg  position,  and  the 
surcreon  should  approach  the  bladder  through  a  transverse,  longitudinal 
or  crescentic  incision  above  the  pubes.  Then,  ha^^ng  seized  the  walls 
of  the  bladder,  he  should  open  it  by  dissecting,  when,  with  a  finger 
in  the  rectum  elevating  the  prostate,  that  gland  is  brought  immediately 


422 


GENITO-IIUNARY    OHCiANS 


into  touch  with  a  finger  entering  the  bhiddcr  from  above.  The  surgeon 
then  incises  the  mucosa  over  the  tumor.  It  is  now  an  (uisy  matter  to 
shell  out  the  enlarged  gland,  which  brings  with  it,  usually,  a  portion  of 
the  prostatic  urethra.  Much  has  been  said  on  the  question  of  remov- 
ing the  prostatic  urethra,  but  the  best  evidence  shows  that  it  is  impos- 
sible to  perform  su]n-a]iubic  prostatectomy  without  damaging  the 
urethra.  The  after-history  of  these  cases  is  so  good,  however,  that 
many  surgeons  have  come  to  feel  such  damage  to  the  ui'cthra  to  be  by 
no  means  permanent — indeed,  to  be  negligible.  The  advantages  of 
suprapubic  enucleation  are  that  the  operation  is  done  through  a  wide 
incision,  that  the  danger  to  the  rectum  and  membranous  urethra  is 


Fi 


Hemostatic  bulb  and  tube  in  place   (J.   1' 


is). 


slight,  and  that  the  whole  maneuver  can  be  performed  quickly.  Hem- 
orrhage generally  is  inconsiderable.  If  the  hemorrhage  does  not  cease 
shortly  with  copious  irrigation,  one  may  well  employ  the  hemostatic 
tube  or  bulb  devised  by  J.  E.  Briggs,  and  shown  in  the  accompanying 
cuts.^  After  the  removal  of  the  prostate,  thorough  drainage  should  be 
established  and  continued  for  at  least  ten  days.  My  custom  is  to  place 
an  inlying  catheter  in  the  urethra,  and  to  sew  a  drainage  catheter  into 
the  bladder  from  above.  I  prefer  to  bring  out  the  suprapubic  drainage 
through  the  middle  of  the  superior  skin-flap,  leading  out  with  it  at  the 
same  time  a  gauze  wick  which  shall  drain  the  prevesical  space.  The 
1  J.  Emmons  Briggs,  New  England  Med.  Gaz.,  April,  1906. 


HYPERTUOrHY    OF   THE    PROSTATE 


423 


v/ick  should  be  removed  after  four  days,  but  the  drainage  catheter 
should  be  left  for  several  days  longer. 

Fretiuentl}'  in  the  case  of  feel)le  old  men  I  have  established  prelim- 
inary drainage  of  the  bladder  through  suprapubic  cystostomy.  At  the 
end  of  a  week,  or  ten  days  often,  it  is  observed  that  the  patient's  general 
condition  has  improved  greatly;  renal  function  has  been  improved, 
and  the  heart  action  is  better  than  before.  One  may  now  proceed 
with  enucleation  of  the  prostate  through  the  already  opened  supra- 
pubic wound,  or,  if  it  seems  best,  one  may  perform 
perineal  prostatectomy.  Occasionally,  it  appears 
that  the  patient  is  too  feeble  to  bear  the  secondary 
operation,  in  which  case  long-continued  drainage 
above  the  pubes  relieves  congestion,  eliminates 
cystitis,  encourages  shrinking  of  the  enlarged  pros- 
tate, and  allows  the  patient,  if  necessary,  to  return 
to  the  catheter  life. 

The  suprapubic  operation  has  found  its  greatest 
favor  among  English  and  Indian  surgeons,  whose 
experience  in  this  method  has  been  large.  Es- 
pecially of  recent  years  has  the  technic  been  im- 
proved, and  has  become  associated  with  the  name 
of  Freyer,  whose  vigorous  advocacy  of  a  rather  an- 
cient practice  has  brought  him  into  prominence 
before  the  surgical  public.^ 

Among  American  surgeons,  however,  the  opera- 
tion of  'perineal  prostatectomy  is  the  favorite.    Numer- 
ous modifications  of  this  operation  have  been  de- 
vised.    Indeed,  it  seems  sometimes  as  though  there 
were  as  many  modifications  as  there  are  operators 
— so  that   I   must   content  myself  with   describing 
what  I  believe  and  have  found  to  be  a  satisfactory 
operation;  essentially  it  is  that  of   Young.-      Be- 
fore  undertaking  the  operation  of   perineal   pros- 
tatectomy the  surgeon  should  have  clearly  in  mind 
answers  to  the  following  five  propositions :  method  of  approach  to  the 
prostate;   method    of   exposing   the   tumor;    method    of   enucleation; 
preservation  of   the  urethra  and  ejaculatory  ducts;  treatment  of   the 
wound. 

The  position  for  the  patient  is  the  exaggerated  lithotomy  position, 
which  can  best  be  secured  by  tipping  up  the  Trendelenburg  table.  I  em- 
ploy the  inverted  V  incision  of  Young  (Fig.  255) ;  rarely  the  simple  median 
incision  advocated  by  Samuel  Alexander,  and  then  in  the  case  of  thin  pa- 
tients only.     On  turning  down  the  skin-flap  the  superficial  muscles  are 

1  There  have  been  humors  even  of  this  controversy.  F.  S.  Watson  recently  al- 
luded to  the  conspicuous  advocate  of  suprapubic  prostatectomy  as  "the  universal 
usurper  of  previously  preempted  prostatic  privileges." 

2  Hugh  H.  Young,  Conservative  Perineal  Prostatectomy,  Jour.  Amer.  Med. 
Assoc,  October  24,  1903,  and  February  4,  1905. 


Fig.  254. — Diagram 
of  hemostatic  tube. 


424 


GEXITO-URIXAKY    ORGAXS 


exposed.  There  are  now  but  two  structures  to  cut  in  order  to  expose 
the  nienibranous  urethra  and  the  prostate.  The  first  structure  is  the 
central  tendon  of  the  perineum  (Fig.  256),  which  passes  fonvard  and  is  in- 
serted into  the  bulb  of  the  urethra.  Cut  this,  and  by  the  same  maneuver 
free  the  sphincter  an!  and  the  levator  ani  from  their  anteiior  attachments. 
This  loosens  the  rectum  also,  though  it  is  still  held  by  the  recto-urethralis 
muscle,  Avhich  comes  immediately  into  view.  One  must  divide  now  this 
muscle,  for  it  is  the  structure  which  holds  forward  the  rectum.  By  its 
division  that  organ  is  allowed  to  fall  back  out  of  the  way  of  further 
dissection.     The  division  of  the  recto-urethralis  and  further  blunt  dis- 


Fig.     255. — Perineal      prostatectomy 
step  1  (redrawn  after  Young). 


Fig.  25fi. — Perineal  prostatectomy — 
step  2.  Exposure  of  central  tendon  by 
bifid  retractor  (redrawn  after  Young). 


section,  with  proper  retraction,  reveal  the  membranous  urethra  and 
the  anterior  portion  of  the  prostate  gland.  At  this  point  a  grooved 
staff  may  be  passed  into  the  urethra,  or  the  staff  maj'  have  been  inserted 
before  beginning  the  operation.  Open  the  membranous  urethra  u]:)on 
the  staff.  The  approach  to  the  field  of  operation  is  now  complete.  In 
order  to  bring  the  tumor  into  proper  view,  use  as  a  routine  the  well- 
known  tractor  of  Young.  One  opens  the  membranous  urethra,  with- 
draws the  staff,  and  passes  the  tractor  into  the  bladder  thi'ough  the 
membranous  and  prostatic  urethra.     One  then  opens  the  blades,  which 


nvri:irn{orHY  of  the  riiosTATio 


425 


arc  nuule  to  lie  across  the  lobes  of  the  prostate.     Then  with  gentle  firm 
traction,  draw  the  prostate  well  clown  into  the  fieltl. 

A'ext  incise  the  two  lateral  lobes  separately.  Having  opened  down 
through  the  capsule,  dissect  out  the  lobes  with  a  blunt  dissector,  seize 
them  with  forceps  (Fig.  258),  and  drag  them  out  until  they  hang  by  their 
prostatic  attachments.  At  this  point  introduce  a  finger  into  the  wound 
so  as  to  make  sure  of  not  tearing  through  into  the  urethra  or  bladder. 
Then  cut  away  with  scissors  the  prostatic  attachments  of  the  lobe,  and 
repeat  the  operation  on  the  other  side.  In  this  way  the  urethra,  the 
ducts,  and  the  bladder  itself  may  nearly  always  be  spared  serious  damage. 


Fig.  257. — Perineal  prostatectomy — 
step  3.  Opening  the  urethra  on  sound 
preparatory  to  introduction  of  tractor 
(redrawn  after  Young). 


Fig.  258 — Perineal  prostatectomy — 
step  4.  Enucleation  of  lobes,  forceps  in 
position  (redrawn  after  Young). 


If  there  be  but  a  small  middle  lobe,  it  may  be  forced  down  into  one  of  the 
cavities  left  by  the  removal  of  the  lateral  lobe,  and  it  maj-  be  seized  and 
extracted  in  much  the  same  manner  as  w^as  the  lateral  lobe  (Fig.  259). 
Sometimes  there  is  a  large  middle  lobe  which  cannot  easily  be  managed 
by  the  tractor.  In  such  a  case  enlarge  the  opening  in  the  urethra,  pass 
the  finger  into  the  bladder  through  the  prostatic  urethra,  and  thus  easily 
bring  down  the  middle  lobe  to  within  reach  for  extraction.  Then,  with 
the  finger  in  the  bladder,  search  thoroughly  that  organ  for  further  ab- 
normalities— sacculations  and  calcuH,  though  such  conditions  should 
have  been  demonstrated  previously  by  the  cystoscope.  The  dressing 
of  the  wound  is  a  simple  matter.     Thorough  drainage  of  the  bladder 


42G 


GEXITO-UIIIXARY   ORGANS 


must  be  instituted.  For  this  })urpose  it  is  Ix'st  to  use  a  large  drainage- 
tube  and  a  small  catheter,  sewed  together  side  by  side,  and  introduced 
through  the  membranous  urethra  into  the  bladder.  By  the  use  of  tliis 
instrument  the  bladder  can  readily  be  washed  out.  Then  pack  hghtly  the 
cavities  with  gauze  wicks  brought  out  at  the  lower  angles  of  the  V- 
shaped  wound,  the  double  drainage-tube  being  led  through  the  middle 
of  the  flap.  The  cut  muscles  of  the  pei-ineum  may  be  restored  with  cat- 
gut stitches;  the  skin  wound  is  then  sewed  up  with  interrupted  silkworm- 
gut  stitches.  Of  the  numerous  modifications  and  changes  in  the  technic, 
I  have  employed  on  three  occasions  the  method  of  Ferg-uson,  who  passes 


"-C. 

n 

\ 

J 

^-J 

\v- 

'  > 

'  1 

1/ 

i 

i 

J 

k 

h 


\ 


Fig.  259. — Perineal  prostatectomy — 
step  5.  Delivery  of  middle  lobe  into 
cavity  of  left  lateral  lobe  (redrawn  after 
Young) . 


Fig.     260. — Perineal     prostatectomy- 
step  6  (redrawn  after  Young). 


a  soft-rubber  catheter  through  tbe  urethral  meatus  for  drainage,  and 
so  into  the  bladder.  In  closing  he  sews  up  the  wound  in  the  mem- 
branous urethra.  Although  this  is  an  excellent  maneuver  in  most  cases, 
I  found  in  one  of  my  cases  that  it  did  not  comfortably  drain  the  bladder, 
and  I  have  returned  to  the  method  described  by  Young — the  double 
drainage-tube  leading  out  through  the  perineum. 

If  all  goes  well,  the  subsequent  history  of  these  cases  is  uneventful. 
Remove  the  drainage-tube  on  the  third  day,  and  the  gauze  packing  on 
the  fifth  day.  There  is  often  more  or  less  perineal  leakage,  but  gener- 
ally the  healing  is  sound.     It  sometimes  happens  that  infection  of  the 


HYPERTROPHY   OF  THE    PROSTATE 


427 


wound  or  a  persistent  cystitis  makes  necessary  frequent  irrigation  of  the 
bladder.  Or  it  may  be  that  the  drainage  is  unsatisfactory.  Under  such 
circumstances  I  have  used  with  advantage  the  apparatus  devised  by  A. 
J.  A.  Hamilton,  and  employed  first  at  the  Carney  Hospital  in  Boston^ 
(Fig.  261) .  By  the  end  of  three;  or  four  weeks  the  patient  should  be  pass- 
mg  his  urine  by  the  natural  channel.  1  like  to  get  these  patients  up  as 
early  as  possible,  and  fre- 
quently have  them  sitting  up  ^ — f  k^  <k=S 
in  a  chair  on  the  third  or 
fourth  day.  As  to  the  preser- 
vation of  the  sexual  power, 
there  is  now  abundant  evi- 
dence to  show  that  in  a  con- 
siderable proportion  of  cases 
this  power  is  preserved,  prob- 
ably more  surely  than  by 
any  other  method.  By  this 
method  also  there  seems  less 
probability  of  setting  up  an 
epididymitis.  Convalescence 
generally  is  short  and  satis- 
factory, and  the  sense  of 
well-being  which  promptly 
returns  to  the  patient  after 
operation  is  gratifying  both 
to  him  and  to  the  surgeon. 
The  operation  of  perineal 
prostatectomy  has  long 
passed  the  experimental 
stage.  Thousands  of  these 
cases  have  now  been  operated 
upon  by  American  surgeons, 
with  increasingly  good  results,  so  that  we  are  justified  in  claiming  for 
perineal  prostatectomy  a  high  place  in  surgical  therapeutics.^ 

Numerous  paUiative  operations  for  enlargement  of  the  prostate  have 
been  advocated  from  time  to  time  in  the  past,  and  I  mention  them  only 
to  protest  against  their  employment.  At  one  time  orchidectomy,  or 
removal  of  the  testes,  promised  great  things.  But  faith  is  necessary  m 
its,  advocate  to  uphold  a  shadow  of  its  claim.  In  the  same  way,  vasec- 
tomy, or  excision  of  portions  of  the  vasa  deferentia,  was  loudly  heralded. 
Nowadays  we  hear  Httle  of  these  operations.  If  they  are  useful,  it  must 
be  mainly  for  the  mental  effect  which  they  produce.  Possibly  one  of 
my  readers  may  be  inclined  to  employ  them  in  the  case  of  hysteric 
individuals  who  refuse  a  more  radical  operation,  but  rarely  othei-wise. 

1  A.  J.  A.  Hamilton,  An  Apparatus  for  the  Intermittent  Post-operative  Drainage 
of  the  Bladder,  Jour.  Amer.  Med.  Assoc,  March  21,  1908.  ,       j*    k 

2  Many  cases  of  functional  failure  after  this  operation  have  been  found  to  be 
due  to  psychic  causes  For  an  important  essay  on  this  subject  see  Samuel  Alexander, 
Contribution  to  the  Surgery  of  the  Prostate,  Ann.  Surg.,  August,  1908. 


Fig.  261.— Hamilton's  bladder  drainage  appa- 
ratus. 


428  GEXITO-LKIXARY    ORGANS 

It  is  11  surprising  fact  that  the  operation  of  oi-chitlectoniy  has  been 
followed  by  a  considerable  mortality  in  cases  of  old  men.  If  cither 
orchidectoni}-  or  vasectomy  be  done,  I  advise  that  the  surgeon  ajiproach 
the  organ  by  the  high  incision  above  Poupart's  ligament,  through 
which  he  may  draw  up  and  excise  the  testicle,  or  readily  remove  a  por- 
tion of  the  vas. 

CANCER  OF  THE  PROSTATE 

Cancer  of  the  prostate  is  not  especially  uncommon  and  deserves 
our  consideration — our  serious  consideration.  Some  genito-urinary 
surgeons  are  coming  to  look  upon  cancer  of  the  prostate  as  less  fatal 
necessarily  than  it  was  regarded  a  few  years  ago,  and  this  feeling  is 
due  to  recent  successes  in  radical  operations  on  prostatic  cancer.  Can- 
cer and  sarcoma  both  occur  in  the  prostate,  but  cancer  is  nine  times 
commoner  there  than  is  sarcoma.  For  years,  writers  have  been  as- 
serting that  cancer  of  the  prostate  has  no  relation  to  prostatic  hy- 
pertrophy. I  believe  that  this  is  a  false  view,  judging  from  my 
own  clinical  experience  and  from  Young's  careful  reports,^  which  state 
that  about  14  per  cent,  of  those  patients  who  apply  to  him  for  prostatic 
obstruction  are  the  victims  of  prostatic  cancer,  often  associated  with 
long-standing  hypertrophy. 

Early  prostatic  cancer  is  confined  to  the  gland  by  the  stout  prostatic 
capsule.  Extension  comes  late  and  involves  the  seminal  vesicles,  the 
bladder,  the  rectum,  and  other  pelvic  organs.  Metastases  are  rare, 
appearing  in  but  few  lymph-nodes,  and,  curiously  enough,  involving  the 
bones  in  many  cases.  The  surgeon  should  have  in  mind  the  possibility 
of  cancer  whenever  he  has  to  deal  with  an  enlarged  prostate,  but  he  will 
find  the  differential  diagnosis  difficult  and  the  symptoms  often  obscure. 
At  first  there  are  diflficulty  of  micturition  and  frequency  merely;  but  in 
about  one-third  of  the  cases  there  is  pain  early,  and  pain  in  all  the  cases 
eventually.  About  20  per  cent,  of  the  cases  have  hematuria  first  or  last. 
The  progress  of  the  disease  is  more  rapid  than  is  benign  enlargement  of 
the  prostate.  One  should  not  overlook  especialh'  the  frequently  extreme 
hardness  of  the  gland,  and  on  cystoscopic  examination  the  absence  gen- 
erally of  lobes  projecting  into  the  bladder,  while  at  the  same  time  the 
urethral  orifice  often  appears  normal.  Pain  is  characteristic,  and  may 
radiate  in  various  directions,  the  patient  describing  pain  over  the  pubes 
or  in  the  perineum,  in  the  thighs,  hips,  rectum,  buttocks,  and  along  the 
sciatic  nerves.  There  is  also  the  common  constitutional  disturbance 
seen  in  cancer.  So  we  base  our  diagnosis  on  the  rapidity  of  the 
growth,  the  increasing  pain,  and  the  induration  of  the  prostate;  some- 
times on  a  constricted  prostatic  urethra  near  the  apex  of  the  gland,  and 
on  the  absence  of  intravesical  lobes.  Of  course,  all  these  signs  and 
symptoms  are  not  necessarily  present  together,  btit  in  any  case,  when 
in  doubt,  the  surgeon  should  advise  operative  exploration  of  the  prostate 
in  order  to  establish  the  diagnosis,  provided  the  patient's  strength 
warrants  this  somewhat  radical  measure. 

1  Hugh  H  Young,  Carcinoma  of  the  Prostate,  Jcur  Amer.  Mod.  Assoc,  March 
10,  1906 


CANCER   OF  THE   PROSTATE 


429 


So  recent  a  writer  as  G.  R.  Fowler,  publishing  in  1906,  states  that 
the  treatment  of  prostatic  cancer  is  purely  palliative.  I  believe  that 
this  is  true  in  advanced  cases  only.  In  the  early  cases  a  radical  prosta- 
tectomy may  cure  the  patient,  or  one  of  the  extensive  operations  sug- 
gested and  practised  by  Kiister,  Harris,  or  Young.  Kiister  removed 
the  whole  bladder  and  implanted  the  ureters  in  the  rectum.  Harris 
excised  the  greater  portion  of  the  bladder  and  transplanted  the  ureters 
into  the  vertex  of  that  organ.  Young's  operation  is  less  dangerous  than 
these,  though  at  the  best  it  is  tedious,  difficult,  and  hazardous  except 


Fig.  262. — Excision  of  cancer  of  the  prostate — step  1  (redrawn  after  Young). 

in  the  most  skilled  hands.     It  has  been  successful  with  a  number  of 
patients. 

Young's  Operation. — Approach  the  prostate  as  for  an  ordinary 
perineal  prostatectomy  through  the  inverted  V-incision.  Open  the 
membranous  urethra  upon  a  grooved  staff,  and  introduce  the  prostatic 
tractor  into  the  bladder  and  open  the  tractor.  While  making  traction 
on  the  prostate  with  this  instrument,  separate  thoroughly  with  scissors 
and  blunt  dissection  the  prostate  and  bladder  before  and  behind  from 
the  neighboring  tissues.     By  this  means  the  mobilized  bladder  may  be 


430 


GENITO-l'RINARY   ORGANS 


drawn  well  down  into  tho  wound.  Cut  off  the  membranous  urethra  in 
front  of  the  tractor;  depress  that  instrument;  open  the  bladder  from  in 
front  with  the  knife,  and  then,  with  the  scissors,  excise  the  lower  portion 
of  the  bladder  with  the  prostate,  seminal  vesicles,  and  j)ortionsof  the  vasa 
deferentia,  cutting  off  the  base  of  the  bladder  about  half  an  inch  in  front 
of  the  openings  of  the  ureters.  We  have  now  brought  away  the  malig- 
nant prostate  with  a  large  margin  of  bladder.  The  stump  of  the  bladder 
falls  far  back,  leaving  a  large  rent  to  repair.  It  is  not  very  difficult  to 
fill  the  gap,  as  indicated  by  the  diagram  in  the  text.  At  one  point  in  the 
anterior  wall  of  the  bladder  a  puckered  opening  is  manufactured  for 


Fig.  263. — Excision  of  cancer  of  the  prostate — step  2  (redrawn  after  Young). 


suture  to  the  stump  of  the  membranous  urethra.  The  remaining  open- 
ing in  the  bladder-wall  is  then  easily  closed  with  stitches.  Young 
recommends  sewing  up  the  rent  with  alternate  catgut  and  silkworm- 
gut  sutures,  the  latter  being  left  long.  The  repair  of  the  urethra  may 
be  made  with  silk  or  catgut  stitches ;  then  an  inlying  catheter  is  fastened 
into  the  bladder,  passing  throughout  the  length  of  the  urethra.  The 
depths  of  the  wound  are  filled  with  light  gauze  packing,  which  is  brought 
out  through  the  perineal  opening,  the  levator  ani  muscles  are  drawn 
together  with  tw'o  catgut  stitches,  and  the  skin-wound  is  closed  so  far  as 
possible. 


CANCER    OF    THE    PRO.STATE 


431 


This  radical  operation,  if  successful,  is  followed  by  a  relatively  short 
convalescence,  and  the  patient  may  be  expected  to  regain  comparative 


Fig.  264. — Excision  of  cancer  of  the  prostate — step  3  (redrawn  after  Young). 


Fig.  265. — Excision  of  cancer  of  the  prostate — step  4  (redrawn  after  Young). 


strength.      Urinary  continence  is  scarcely  to  be  hoped  for,  however, 
though  in  some  of  the  cases  the  incontinence  is  not  complete.     The 


432 


GEXITO-UIUXAIIY    OllGAXS 


dangers  from  hemorrhage  and    from   shock   during   the  operation  are 
great.     \'iewcd  as  a  radical  advance  in  surgery,  the  operation  often 


Urethra 


Fig.  266. — Excision  of  cancer  of  the  prostate — step  5  (redrawn  after  Young). 

may  seem  preferable  to  palliation  with  the  certainty  of  an  earl}'  death, 

and  patients  occasionally  may   be    found 
who  prefer  to  take  the  surgical  risk. 

The  rare  cases  of  sarcoma  of  the  pros- 
tate have  never  been  subjected  to  surgical 
operation,  so  far  as  I  am  aware;  but  the 
treatment  of  such  tumors  should  be  es- 
sentially the  same  as  that  for  cancer. 

There  are  a  few  other  rare  prostatic 
tumors  which  we  have  space  to  mention 
merely:  hydatids;  cystic  dilatation  of  the 
prostatic  vesicles;  and  retention  cysts 
(distention  of  occluded  glands  or  fol- 
licles). Papilloma  of  the  prostate  may 
develop  in  connection  with  papilloma  of 
the  bladder. 

Such  are  the  more  common  and  im- 
portant diseases  of  the  bladder  and  pros- 
tate. I  have  pointed  out  their  intimate 
association  with  disorders  of  the  kidneys. 
In  the  next  chapter  we  shall  consider  the 
terminal    portion    of    the    genito-urinary 

apparatus,  whose  diseases  also  are  closely  associated  often  with  those 

of  the  prostate  and  bladder. 


Fig.  267. — Diagram  showing 
plan  of  vesico-urethral  anasto- 
mosis (Young  in  Keen's  Sur- 
gery). 


CHAPTER   XV 

PENIS,   URETHRA,   AND   TESTES 

The  Penis  and  Urethra 

Diseases  of  the  penis  and  urethra  concern  all  physicians  as  well 
as  surgeons,  for  it  has  been  estimated  that  more  than  70  per  cent,  of 
mankind,  first  and  last,  fall  victims  to  venereal  disease,  and  venereal 
disease  represents  the  vast  majority  of  diseases  of  these  organs.  It  is 
needless  here  to  discuss  the  social  and  ethical  questions  involved, 
and,  indeed,  this  subject  has  become  a  commonplace  of  medical  litera- 
ture. It  is  well,  however,  to  remind  the  reader  that  venereal  disease 
is  a  matter  of  first  importance,  not  only  to  the  immediate  victim,  but 
to  his  family  and  offspring.  The  penis  in  the  male  has  no  proper 
analogue  in  the  anatomy  of  the  female,  for  the  penis  is  an  organ  of 
double  function:  it  serves  as  a  passage  for  urine,  as  well  as  for  the 
act  of  procreation. 

Let  us  consider  briefly  the  anatomy  of  the  urethra.  The  urethra 
in  the  male  is  about  7  to  8  mches  long,  and  is  divided  mto  four  portions : 
the  fossa  navicularis,  which  lies  within  the  glans  penis;  the  penile  or 
spongy  portion,  occupying  about  4  inches,  and  dilated  at  its  internal 
end  into  a  bulbous  portion;  the  membranous  urethra,  about  ^  inch  long; 
and  the  prostatic  urethra,  about  1|  inches  long.  The  shape  and  caliber 
of  the  urethra  vary  and  alter  with  each  of  these  portions.  At  the 
extremitj'  of  the  penis  the  urethra  begins  with  the  meatus^  a  vertical 
slit;  then  it  widens  immediately  into  the  fossa  navicularis,  then  narrows 
into  the  spongy  or  penile  urethra,  which  ends  in  the  sacculated  bulb; 
immediately  behind  the  bulb  there  lies  within  the  triangidar  ligament 
the  membranous  urethra,  which  is  narrow  and  inelastic,  while  behind 
the  membranous  urethra  is  the  wider  and  distensible  prostatic  urethra. 
One  sees  that  this  canal  is  not  a  straight,  uniform  drainage-tube,  but 
that  with  its  broadening  and  narrowing  it  offers  abundant  chance  for  the 
lodgment  of  infecting  material  and  collections  of  mflammator}-  exudate. 
Moreover,  there  are  accessories  to  the  urethra^accessories  which  give 
additional  opportunity  for  the  lodgment  of  infecting  organisms.  In 
the  central  portion  there  are  the  glands  of  Littre,  and  in  the  fossa 
navicularis  one  large  gland  or  follicle  on  the  upper  surface,  about  an 
inch  from  the  meatus.  This  is  called  the  lacuna  magna,  and  when  it 
becomes  infected  with  gonorrhea,  it  may  remain  locally  inflamed  long 
after  other  portions  of  the  urethra  are  free  from  disease.  Opening  into 
the  bulbous  portion  are  the  two  ducts  of  Cowper's  glands,  while  in  the 

28  433 


434  GEXITO-URIXARY   ORGANS 

prostatic  urethra,  in  the  middle  line,  lies  the  venimontanum,  on  each 
side  of  which  arc  the  prostatic  sinuses,  and  in  these  the  oi'ifices  of  the 
prostatic  glands.  Near  the  crest  of  the  verumontanum  is  the  utriculus, 
which  carries  the  openings  of  the  ejacvdatory  ducts.  Arranged  about 
the  membranous  urethi'a,  and  lying  in  the  folds  of  the  triangular  liga- 
ment, are  the  fibers  of  the  compressor  urethra.",  or  cut-off  nmscle,  the 
great  dividing  line  between  the  anterior  and  posterior  urethra,  I  urge 
the  student  to  remember  this  anatomic  landmark,  the  triangular  liga- 
ment, for  upon  its  relation  to  the  urethra  de}3cnd  numerous  pathologic 
conditions  and  the  application  of  sundry  therapeutic  measures. 

Of  what  sort,  then,  is  this  venereal  disease  which  afflicts  mankind? 
We  use  the  terms  syphilis  and  gonorrhea  to  describe  it.  Up  to  the  midtlle 
of  the  last  century  the  best  teaching  informed  students  that  syphilis 
and  gonorrhea  were  identical,  and  we  hear  the  pretty  fable  of  John 
Hunter's  inoculating  himself  with  the  virus  of  gonorrhea  and  producing 
syphilis.  By  this  experiment  he  proved  to  the  satisfaction  of  the 
scientific  world  that  gonorrhea  and  s}'philis  are  one.  We  must  now  sup- 
pose that  he  was  mistaken  in  his  original  diagnosis  of  the  case  from 
which  he  took  the  virus.  Doubtless  he  secured  the  exudate  from  a 
syphilitic  chancre,  thinking  it  to  be  gonorrheal  pus.  The  great  surgeon 
and  teacher  who  differentiated  gonorrhea  from  syphilis  was  Philippe 
Ricorcl,  who  published,  in  1836,  more  than  sixty  years  after  John  Hun- 
ter's hazardous  experiment.  In  some  fashion  not  altogether  unworthy 
of  present-day  pathology  Ricord  explained  the  distinction  between  the 
two  diseases.  It  is  not  surprising,  however,  that  he  failed  to  recognize 
the  fact  that  gonorrhea  is  due  to  a  specific  virus.  He  asserted  that  it  is  a 
catarrhal  condition  induced  by  a  variety  of  causes. 

GONORRHEA 

Gonorrhea  begins  as  an  acute  localized  inflammation,  which  may 
become  chronic  and  may  become  systemic.  The  majority  of  cases 
cease  with  the  acute  stage,  and  are  limited  to  an  anterior  urethritis; 
a  considerable  number  of  cases  progress  to  a  chronic  involvement  of  the 
posterior  urethra,  the  bladder,  the  seminal  vesicles,  the  prostate,  the 
vasa  deferentia,  and  the  testes;  a  comparatively  small  proportion  involve 
serous  surfaces,  especially  the  joints,  the  heart,  and  the  peritoneum. 
These  statements  apply  to  gonorrhea  in  the  male.  In  the  case  of  the 
female,  as  I  stated  in  Chapter  X,  gonorrhea  is  limited  at  first  to  the  ure- 
thra and  vulva,  and  then,  sparing  the  vagina  generally,  it  penetrates 
to  the  uterine  mucosa,  the  tubes,  and  ovaries.  In  this  chapter  we  are 
dealing  with  gonorrhea  in  the  male. 

Although  the  infection  takes  place  from  direct  sexual  contact  in 
most  cases,  there  can  be  no  doubt  that  rare  unfortunate  individuals  are 
infected  from  contact  with  gonorrheal  pus  on  towels  and  in  unclean 
water-closets.  A  most  lamentable  instance  of  innocent  gonorrheal  in- 
fection is  gonorrheal  conjunctivitis,  which  is  brought  to  the  eye  on 
soiled  fingers  and  towels,  or,  in  the  case  of  the  new-born,  from  the 


GONORRHEA  435 

infected  parts  of  the  mother,  and  sets  up  an  alarming  and  destruc- 
tive process  within  the  orl)it.  In  oi'cHnary  acute  gonorrheal  urethritis, 
however,  the  si)ecifi(!  poison  is  deposited  upon  or  within  the  meatus, 
where  the  organisms  incubate  for  from  two  to  five  days ;  then  an  inflam- 
matory reaction  occurs  and  causes  symptoms,  which  inform  the  patient 
of  his  misfortune.  At  first  there  is  a  slight  itching  and  burning,  with 
mod(n'ate  scalding  on  micturition;  then  comes  a  purulent  discharge, 
beginning  as  a  mere  drop,  but  rapidly  increasing.  At  this  time  the 
infection  has  not  progressed  beyond  the  fossa  navicularis.  If  you 
examine  the  discharge  of  pus,  you  will  find  early  that  it  contains  leuko- 
cytes with  a  few  diplococci  (gonorrheal  cocci)  outside  the  cells.  Soon, 
however,  the  diplococci  penetrate  within  the  cells,  and  there  charac- 
teristically they  are  to  be  found  on  proper  staining.  In  every  case  of 
urethritis  the  surgeon  should  make  three  or  four  cover-slip  preparations 
and  examine  for  the  diplococci.  These  are  the  gonococci'of  Neisser, 
who  first,  in  1879,  demonstrated  this  organism  as  essential  to  true 
gonorrhea.  After  obtaining  a  lodgment  the  organisms  penetrate  rapidly 
through  the  epithelial  layers  of  the  urethra  and  enter  the  submucous 
tissue;  then,  with  the  onset  of  the  inflammatory  reaction,  a  fresh  and 
more  abundant  discharge  of  pus  takes  place,  and  the  acute  stage  of  the 
disease  progresses  rapidly.  The  more  abundant  the  suppuration,  the 
more  effectually  are  the  gonococci  removed  from  the  tissues,  so  that 
the  inflammation  may  properly  be  regarded  as  a  salutary  action  of 
nature.  In  view  of  this  fact,  therefore,  physicians  have  come  to  realize 
that  measures  for  checking  violently  the  early  discharge  are  not  properly 
employed.  The  infection,  with  its  accompanying  inflammation,  spreads 
along  the  anterior  urethra  as  far  as  the  compressor  urethrse  muscle, 
and  involves  all  this  anterior  portion  of  the  membrane  in  the  course  of 
the  first  week  from  the  appearance  of  symptoms.  The  rare  cases  of 
gonorrhea  which  progress  without  suppuration  are  to  be  dreaded,  for 
in  such  case  the  disease  destroys  tissue  at  an  astonishing  rate.  The 
cut-off  muscle  is  the  first  anatomic  barrier  which  a  progressive  gonorrhea 
encounters,  and  in  many  cases  this  barrier  is  the  limit  of  the  process. 
Frequently,  however,  gonorrhea  proceeds  and  involves  deeper  structures. 
In  the  progress  of  the  infection  the  discharge  increases  at  first,  and  then 
subsides  slowly,  as  more  and  more  of  the  organisms  are  eliminated.  The 
discharge  becomes  less  purulent  and  more  mucous,  until  it  appears  as 
a  mere  mucous  secretion.  In  this  form  it  persists  and  represents  the 
chronic  gonorrhea  or  gleet,  the  clread  of  patients  and  surgeons.  It  is 
difficult  to  say  at  what  period  in  time  an  acute  gonorrhea  passes  over 
into  the  chronic  stage,  but,  in  general  terms,  you  may  tell  your  patient 
that  a  urethritis  is  chronic  which  persists  more  than  six  weeks. 

There  are  non-specific  forms  of  urethritis — forms  which  are  some- 
times called  bastard  gonorrhea,  and  these  forms  are  not  uncommon. 
Mostly  they  are  relatively  simple  and  easily  cured;  sometimes  they  are 
obstinate  and  chronic.  The  commonest  exciting  causes  of  non-specific 
urethritis  are  so-called  uric-acid  excess,  systemic  fever,  traumatism, 
syphilis,  tuberculosis,  and  invasions  of   pus-producing  bacteria  other 


436  GENITO-URINARY   ORGANS 

than  gonococci.  Many  of  these  infections  subside  quickly  with  simple 
cleansing  irrigations,  but  others,  notably  tuberculous  anrl  syphilitic 
infections,  seem  hopelessly  obstimite. 

The  treatment  of  acute  gonorrhea'  falls  largely  to  young  ])racti- 
tioners.  foi'  tlic  acute  guuonhca  of  men  is  a  tlisease  of  youth,  and  young 
men,  in  their  mortification  antl  distress,  naturally  hesitate  to  consult 
their  elders.  When  a  patient  with  suspected  gonorrhea  consults  the 
surgeon,  the  first  anfl  important  purjjose  of  the  latter  is  to  confirm  the 
diagnosis,  and  the  one  final  test  is  to  demonstrate  the  gonococcus  of 
Neisscr.  With  the  diagnosis  made,  it  is  the  surgeon's  imperative  duty 
to  explain  carefully  the  situation  to  the  victim.  He  nmst  point  out  to 
him  the  danger  to  himself  and  the  danger  to  others.  Incredible  as  it 
may  seem,  one  meets  frequently  with  ignorant  patients  who  have  been 
taught  the  old  tradition  that  the  best  cure  for  gonorrhea  is  further 
repeated  sexual  intercourse.  I  have  already  indicated  the  danger  to 
others.  The  immediate  danger  is  transmission  of  the  virus,  and  this 
should  be  guarded  against  by  abstinence  from  venery;  while  the  patient 
should  ])e  warned  to  use  his  own  individual  towels  and  underclothes,  and 
to  scrub  his  hands  after  every  handling  of  the  parts.  To  avoid  needless 
danger  to  himself  he  should  take  pains  not  to  rub  his  eyes  with  his 
fingers,  not  to  bottle  up  the  urethral  discharge  b)^  packing  a  cotton  plug 
about  the  meatus,  and  he  should  be  instructed  to  wear  a  suspensor}'- 
bandage  from  the  start.  The  internal  treatment  is  not  to  be  neglected; 
the  patient  should  eat  a  light  diet,  with  meat  once  a  day,  with  no  fats, 
fruit,  alcoholic  drinks,  or  highly  spiced  dishes ;  and  he  should  be  encour- 
aged to  drink  freely  skimmed  milk  and  some  aerated  water.  I  think 
the  value  of  copaiba  and  sandalwood  oil  has  been  underestimated.  One 
of  them  should  be  given,  in  five-minim  capsules,  and  the  daily  dose 
should  be  increased  up  to  the  point  where  it  causes  gastric  distress — 
3,  9,  12  capsules  daily. 

During  the  acute  stage  of  the  disease  the  patient  should  avoid  all 
violent  exercise;  he  should  walk  as  little  as  possible;  he  should  not  ride 
or  drive  if  it  can  be  avoided,  and,  above  all  things,  he  should  not  take  a 
railway  journey.  Rest  in  bed  is  his  best  course,  if  he  can  be  persuaded 
to  it.  I  have  said  that  the  surgeon  should  prescribe  no  strong  anti- 
septic injections  or  irrigations  to  control  the  discharge  for  the  first  few 
days.  This  statement  holds  true  of  all  antiseptics  known  to  me  with 
the  single  exception  of  argyrol.  This  drug,  in  the  solution  of  10  or  20 
per  cent.,  may  be  employed  for  injections  by  the  surgeon  in  his  office, 
and  a  10  per  cent,  solution  mav  he  given  to  the  patient  to  use  at  home. 
Argyrol  acts  best  when  injected  three  or  four  times  a  day,  and  held  in  the 
urethra  for  at  least  ten  minutes  at  each  injection.  The  theory  is  that  it 
penetrates  the  tissues  without  damaging  their  structure,  and  reaches 
the  organisms   in  sufficient   volume   and   strength  to   destro}^  them. 

1  The  careful  researches  Ijeing  carried  on  in  the  MacArthur  clinic  in  Chicago 
assure  us  that  in  the  gonococcus  vaccines  we  have  a  remedy  which  shortens  and 
ameliorates  the  course  of  gonorrhea,  especially  when  the  ordinary  cleansing  and 
hygienic  measures  also  are  employed.  This  combination  of  treatment  is  effective 
in  tlie  case  of  women  also. 


GONORRHEA 


437 


Argyrol  thus  used  certainly  will  cut  short  many  cases  of  gonorrhea, 
sometimes  limiting  the  duration  of  the  attack  to  a  week  or  ten  days. 

If  the  urine  remains  thready  after  a  week  of  argyrol  treatment  has 
elapsed,  especially  if  there  continues  a  mucous  discharge,  the  surgeon 
may  prescribe  a  mild  solution  of  astringents  as  an  injection,  to  be  used 
twice  daily,  and  held  in  not  more  than  one  minute.^  When  employmg 
injections  of  any  kind,  the  patient  should  use  a  half-ounce  blunt-nozzle 
syringe,  which  will  not  penetrate  the  urethra.  The  popular  long-nozzle 
syringe,  which  can  be  passed  up  an  inch  or  more  into  the  urethra,  is  an 
abomination. 

During  the  apparent  subsidence  of  the  acute  attack  the  posterior 
urethra  may  become  involved  in  the  disease.  To  ascertain  this,  use  the 
two-glass  test— having  the  patient  pass  part  of  his  urine  into  one  glass, 
and  the  remainder  into  a  second  glass.  Cloudy  urine  in  both  glasses 
shows  that  the  disease  has  attacked  the  posterior  urethra;  doudy  urme 
in  the  first  glass  only  shows  that  the  gonorrhea  is  still  anterior.  In  case 
one  is  dealing  with  a  posterior  urethritis  at  this  time,  an  admn-able 
treatment  is  to  make  deep  instillations  with  20  per  cent,  argyrol  mto 
the  posterior  urethra.  This  may  be  done  with  an  Ultzmann  syrmge,  a 
few  drops  only  being  injected.     The  anterior  urethritis  must  be  treated 


Fig.  268.— Ultzmann's  syringe  for  instillation  (Greene  and  Brooks). 

at  the  same  time,  as  I  have  advised.  Strong  irritating  injections  of 
corrosive  sublimate  or  silver  nitrate  should  never  be  used  m  an  acute 
gonorrhea,  nor  should  instruments,  such  as  sounds  or  the  endoscope,  be 
passed  at  this  time  to  dilate  the  urethra  or  inspect  its  surface.  _ 

Chordee  is  a  painful  erection  of  the  penis,  and  is  due  to  the  mability 
of  the  corpus  spongiosum  surrounding  the  urethra  to  distend  properly 
in  the  act  of  erection.  Chordee  occurs  commonly  at  night  or  m  the 
early  morning,  when  the  bladder  is  full.  ■  It  may  be  relieved  by  active 
walking  about,  by  the  appHcation  of  ice,  and,  if  obstinate,  by  a  small 
dose  of  opium.  To  relieve  the  pain  of  urination  immerse  the  penis  m 
hot  water  during  the  act. 

Epididymitis,  single  or  double,  may  occur  in  the  course  ot  an  acute 
gonorrhea.  It  is  due  either  to  the  direct  infection  of  the  vasa  deferentia 
and  epididymis,  from  the  inflamed  posterior  urethra,  or  to  transmission 
through  the  lymphatics.     As  a  rule,  epididymitis  yields  readily  to  treat- 

1  An  excellent  astringent  injection,  which  I  have  long  used  with  satisfaction, 

is  this:  ,^  „^„,-t,c. 

I^.    Sulphate  of  zinc 16  grains 

Acetate  of  lead -^^  , 

Tinct.  catechu \  ^ram 

Wine  of  opium :     J 

Water ^^     6  ounces. 


438  GEXITO-URIXARY   ORGANS 

ment.  The  patient  should  l)e  put  to  bed,  the  testicles  should  be  sup- 
ported on  a  towel  or  a  pillow  between  the  legs,  and  an  ice-bag  should  be 
applied  to  the  parts.  A  liquid  diet  should  be  enjoined,  potassium 
citrate  being  given  freely,  with  abundance  of  water  to  drink,  and  opium 
sujjpositories,  if  necessary,  for  pain.  An  interesting  feature  of  this 
complication  is  that  during  the  height  of  the  attack  of  epididymitis 
the  urethral  discharge  is  wont  to  disappear,  reappearing  again  with  the 
subsidence  of  the  epididymitis.  The  swollen  epididymis  may  distend 
the  scrotum  to  the  size  of  a  hen's  egg,  or  even  to  the  size  of  two  fists,  and 
often  the  patient  is  afflicted  by  the  discouraging  thought  that  the 
affected  testicle  will  remain  fuuctionless.     Indeed,  double  epididymitis 


/ 


/ 


Fig.  269. — Adhesive  plaster  applied  to  testis. 

is  a  common  cau.se  of  sterility.'  If  the  applications  and  remedies  already 
suggested  do  not  relieve  the  epididymitis,  the  actual  cautery  may  be 
found  effective,  the  skin  over  the  inflamed  organ  being  lightly  touched 
with  the  white-hot  point.  This  treatment  is  followed  by  the  application 
of  iodoform  ointment.  Sometimes  a  creolin  poultice,  1:  200,  will  relieve 
quickly  pain  and  swelling.  Strapping  the  testicle  with  bands  of 
adhesive  plaster  occasionally  serves  a  good  purpose,  but  the  strapijing 
should  be  applied  by  an  expert.     In  rare  and  obstinate  cases  the  epi- 

1  In  this  connection  see  Edward  Martin,  Sur  ical  Treatment  of  Sterility,  Amor. 
Med.,  1903,  vol.  vii,  p.  791;  and  W.  C.  Quinby,  Sterility  in  the  Male:  Its  Operative 
Treatment  when  Due  to  Bilateral  Epididymitis,  Boston  Med.  and  Surg.  Jour.. 
November  8,  1906. 


GONORRHEA  439 

didymis  and  testicle  become  extremely  diseased,  the  contents  of  the 
scrotum  breaking  down  into  a  suppurating  mass.  In  such  case  our 
resort  is  orchidectomy.  Sometimes,  in  the  case  of  recurrent  epididy- 
mitis, section  of  the  vas  deferens  is  necessary. 

Acute  prostatitis  may  be  treated,  when  fresh,  by  instillations  of  20 
per  cent,  argyrol.  I  have  already,  in  Chapter  XIV,  considered  the 
further  progress  of  prostatitis. 

Gonorrheal  bubo,  or  infection  of  the  inguinal  lymph-nodes,  is  a  not 
uncommon  complication  of  gonorrhea.  If  the  case  be  taken  promptly 
and  proper  remedies  be  applied,  this  adenitis  will  subside  without  special 
trovible.  The  proper  remedies  consist  in  active  treatment  of  the  urethra 
and  in  painting  the  bubo  with  tincture  of  ioclin,  putting  on  three  or  four 
coats  every  fourth  night.  If  the  bubo  suppurates,  it  must  be  opened 
and  packed.     Of  course,  the  hair  in  the  groin  should  be  shaved  first. 


I-      -  ..3E 

Fig.  270. — Paraphimosis. 

Balanitis  and  posthitis  are  inflammations  of  the  glans  and  prepuce, 
and  are  due  to  an  extension  of  the  gonorrheal  process  from  the  meatus. 
Hy  proper  cleanliness  such  complications  should  be  forestalled.  The 
surgeon  may  treat  them  by  directing  the  patient  to  draw^  back  the 
prepuce  two  or  three  times  a  day,  to  soak  the  penis  in  a  warm  solution 
of  creolin  and  water,  and  to  dust  the  glans  with  a  drying  powder  of 
equal  parts  of  borax  and  zinc  oxid,  to  which,  if  you  choose,  a  quarter 
part  of  powdered  opium  may  be  added.  If  there  be  actual  ulceration, 
powdered  iodoform  makes  an  excellent  application  in  spite  of  its  disagree- 
able odor. 

Phimosis  and  paraphimosis  are  akin.  Phimosis  is  the  result  of 
inflammation  of  the  prepuce,  an  inflammation  so  severe  that  the  prepuce 
becomes  distended  and  its  orifice  narrowed,  so  that  it  cannot  be  drawn 


440 


GENITO-URINAKY   ORGANS 


back  over  the  glans.  As  a  result,  secretions  accumulate  beneath  it  and 
a  foul  condition  of  the  or^an  results.  If  the  swelling  takes  place  when 
the  prepuce  is  retracted  above  the  glans,  the  constriction  occurs  Ix'hind 
the  corona,  with  the  result  that  the  foreskin  cannot  be  drawn  down 
over  the  glans.  This  is  the  condition  of  paraphimosis,  a  far  more  serious 
affair  than  phimosis.  The  surgeon  may  treat  phimosis  by  lead  and 
opiimi  lotions,  or  lead  and  carbolic  lotions,  at  the  same  time  keeping  the 
parts  thoroughly  clean  by  injecting  warm  water  beneath  the  prepuce. 
It  is  an  excellent  plan  also  to  soak  the  organ  in  a  tumbler  of  weak 
creolin  and  water  two  or  three  times  a  day.  You  will  be  tempted  to 
perform  circumcision,  but  such  a  procedure  is  unw^arranted  at  this 
stage,  because  the  inflamed  prepuce  is  sure  to  slough  when  cut.  A 
later  circumcision  should  be  advised.     The  reduction  of  a  paraphimosis 


Fig.  271. — Reduction  of    paraphimosis 
— first  method  (Fowler). 


Fig.   272. — Reduction   of    paraphimosis 
— second  method  (Fowler). 


is  rarely  an  easy  matter.  Sometimes  the  constricting  band  may  be 
relieved  by  long  immersion  in  cold  water,  after  which  digital  reduction 
should  be  attempted.  Before  doing  this  it  is  well  to  give  the  patient  a 
hypodermic  of  morphin.  I  show  here,  by  illustrations  taken  from 
Fowler's  excellent  book,  two  methods  of  reducing  a  paraphimosis. 
If  reduction  cannot  be  accomplished  by  such  means  after  twelve  or 
twenty-four  hours,  the  constricting  band  must  then  be  cut.  If  it  is  left, 
gangrene  of  the  prepuce  and  glans  will  follow.  The  band  may  readily 
be  divided  by  passing  a  blunt-pointed  bistoury  beneath  the  prepuce 
and  constriction  and  cutting  upward  until  the  foreskin  slides  back  iiito 
place.  After  this  little  operation,  cleanse  the  parts  with  creolin  or 
bichlorid. 

Gonorrheal    cystitis    yields    usually    and    readily    to    treatment. 
Obviously,  it  is  a  sequel  to  posterior  urethritis,  and  when  associated  with 


GONORRHEA  441 

acute  gonorrhea,  it  may  be  demonstrated  by  the  three-glass  test.  If 
the  urine  in  the  third  gkiss  contains  pus  and  shreds,  that  is  fairly  good 
evidence  of  a  gonorrheal  cystitis.  But  far  better  evidence  are  the 
symptoms  of  the  patient,  who  complains  of  straining,  frequency,  hema- 
turia, and  painful  micturition.  Usually  a  course  of  urotropin,  7^ 
grains  in  a  glass  of  water  every  four  hours  for  two  or  three  days,  will 
relieve  completely  the  cystitis.  This  treatment  may  be  supplemented 
by  cold  applications  to  the  perineum  and  hypogastrium  or  by  poultices; 
at  the  same  time  diluent  drinks,  especially  skimmed  milk,  and  abundance 
of  water  should  be  given,  and  pain  should  be  controlled  by  opium  sup- 
positories. 

Such  are  the  commoner  complications  of  acute  gonorrhea.  Let  us 
now  consider  briefly  the  course,  pathology,  and  treatment  of  chronic 
gonorrhea. 

Chronic  Gonorrhea,  or  Gleet. — When  the  patient  comes  to  you 
with  a  history  of  a  venereal  disorder  running  over  from  one  to  ten  years, 
he  will  lament  in  somewhat  the  following  strain :  he  acquired  his  initial 
infection  when  a  young  lad ;  after  a  few  weeks  he  thought  himself  cured 
and  abandoned  treatment;  then  he  had,  at  intervals  of  a  few  months 
or  years,  fresh  outbreaks  of  discharge  from  the  urethra,  for  which  he 
could  not  well  account.  These  outbreaks  were  far  less  violent  and  dis- 
tressing than  the  primary  attack,  but  always  subsided  slowly.  Then 
in  the  course  of  time  he  found  himself  continually  annoyed  by  a  slight 
discharge,  appearing  often  in  the  morning  only,  as  a  drop  (goutte  mili- 
taire),  sometimes  being  no  more  than  a  gumming  together  of  the  lips 
of  the  meatus.  There  have  been  a  continual  sense  of  discomfort  about 
the  organs,  a  feeling  of  weight  in  the  perineum,  frequency  of  micturition, 
perhaps  a  narrowing  of  the  urinary  stream,  and  a  sense  of  chronically 
impaired  health.  Such  a  patient  as  this  comes  to  hate  himself  often, 
and  to  curse  existence.  He  may  develop  sundry  neurotic  symptoms 
and  is  continually  on  the  lookout  for  improbable  evils  of  which  he  may 
have  read. 

The  location  of  the  chronic  disease,  whose  symptoms  I  have  pictured, 
is  a  matter  of  first  inquiry  to  the  surgeon.  If  you  recall  the  anatomy 
of  the  parts  and  the  course  of  an  acute  gonorrhea,  you  will  perceive 
how  readily  organisms  may  find  lodgment  in  obscure  lurking-places, 
where  they  appear  to  remain,  in  an  almost  dormant  condition  often, 
for  years,  aroused  occasionally  to  make  trouble,  and  always  a  burden. 
From  the  lacuna  magna,  through  the  glands  of  the  penile  urethra, 
Cowper's  glands,  the  prostatic  sinuses,  and  the  various  ducts  and  crypts 
of  the  deeper  parts  to  the  seminal  vesicles  and  epididymis,  foci  of  dis- 
ease may  be  found.  Moreover,  there  are  often  ulcerations,  of  greater 
or  less  extent,  which  in  themselves  produce  a  discharge  and  an  increasing 
discomfort. 

The  surgeon  must  examine  his  patient  with  all  these  considerations 
in  mind.  He  should  strip  the  man  and  investigate  carefully  the  whole 
region, — penis,  meatus,  urethra,- — tracing  with  his  fingers  the  thickened 
corpus   spongiosum,    inguinal   nodes,   prostate,   seminal   vesicles,    and 


442  GEXITO-URINARY    ORGANS 

testes.  He  should  inspect  the  urethra  with  the  endoscope  to  discover 
patches  and  inflamed  crypts;  he  should  pass  proper  bougies  or  exploring 
instruments  to  discover  the  caliber  of  the  urethra  and  the  possible 
presence  of  stricture,  and  he  should  determine  the  presence  of  gonococci 
in  an}'  discharge.  At  the  same  time,  in  making  his  cover-slip  examina- 
tion, he  should  note  the  relative  proportion  of  leukocytes,  mucus,  fibrin, 
and  e])ithelial  cells.  At  this  stage  the  two-glass  test  is  of  little  value, 
for  if  there  bo  but  a  slight  exudate  in  the  posterior  urethra,  it  is  carried 
out  com])lctely  by  the  urine  into  the  first  glass.  One  may  learn  better 
the  condition  of  the  posterior  urethra  by  washing  out  first  through  a  soft 
catheter  the  anterior  urethra  with  a  4  per  cent,  boric-acid  solution. 
Then  urine  passed  into  a  glass  will  carry  with  it  detritus  from  the  pos- 
terior urethra  only.  It  has  long  been  customary  to  draw  conclusions 
from  the  appearance  of  urine  thus  passed.  When  the  discharge  is  pro- 
fuse, we  find  in  the  urine  a  turbidity  which  does  not  clear  up  as  does  a 
phosphaturia  on  adding  acetic  acid.  When  the  discharge  is  scanty, 
we  find  floating  particles — the  so-called  Tripperfaden.  These  are  little 
casts  of  the  tubules,  and  are  composed  of  epithelium  with  other  mate- 
rial more  or  less  adherent.  If  there  be  adherent  pus,  the  shreds  sink 
quickly  in  the  glass.  If  there  be  but  epithelium,  mucus,  and  fibrin, 
they  float  or  sink  slowly;  but,  after  all,  this  sign  is  of  no  great  value. 

The  treatment  of  gleet  is  simple  enough  in  theory.  It  involves  the 
finding  and  dislodging  of  gonococci,  and  in  the  resolving  of  areas  of 
exudate  and  thickening.  But  in  fact  these  measures  are  not  easily 
carried  out;  you  may  proceed,  however,  in  somewhat  the  following 
fashion,  with  the  conviction  that  treatment  steadily  pursued  for  a  long 
time  usually  will  cure  the  patient — argyrol  and  urethral  dilators  form 
the  armamentarium.  Instruct  the  patient  to  use  a  10  per  cent,  injec- 
tion of  argyrol  twice  daily  for  three  days.  Then  begin  dilating  the 
urethra.  Ascertain  at  the  first  dilatation  the  topography  of  the  canal. 
For  this  the  instrument  of  Otis  or  the  branched  dilators  of  Kollmann 
are  good.  These  instruments  may  be  passed  easily  into  the  average 
urethra,  and  the  terminal  bulb  of  the  instrument  may  then  be  dis- 
tended so  as  to  define  variations  in  the  urethral  canal.  The  dilator 
may  be  used  for  stretching  abnormal  plastic  constrictions  at  the  same 
time.  In  other  words,  one  employs  a  species  of  massage  along  the 
urethra,  stretching  and  rubbing  out  exudations.  The  old-fashioned 
sounds  are  extremely  useful  also  for  ironing  out  the  urethra.  In  con- 
junction with  this  species  of  mechanical  massage,  argyrol  should  be 
continued,  and  it  is  as  well  used  by  the  patient  at  home.  I  believe 
arg3'rol  to  be  the  only  trul}'  effective  antiseptic  lotion  for  the  urethra, 
and  I  believe  also  that  the  potassium  permanganate  and  other  irriga- 
tions of  a  few  years  ago  are  much  less  effective.  I  no  longer  use  irriga- 
tions. 

This  ironing  out  of  the  urethra  and  soaking  with  argyrol  cures  the 
disease  in  a  great  many  cases ;  and  these  are  the  cases  especially  in  which 
the  inflammation  is  confined  to  the  more  anterior  pcri-urethral  tissues, 
without  the  formation  of  extensive  ulcerations  or  of  organic  stricture. 


GONORRHEA  443 

Briefly,  the  sundry  complications  may  be  dealt  with  as  follows:  there 
may  be  a  false  meatus  or  short,  blind  pouch  in  the  gians.  This  pouch 
usually  opens  on  one  side  of  the  true  meatus  and  should  be  thoroughly 
cleaned  out  and  touched  with  a  stick  of  silver  nitrate.  A  tight  meatus 
must  be  enlarged,  for  often  a  tight  meatus  admitting  no  more  than  a 
No.  20  sound  is  the  terminus  of  a  urethra  of  No.  35  caliber.  Do  not 
carelessly  slash  the  meatus  or  snip  it  with  scissors.  Cocainize  the  glans, 
and  enlarge  the  meatus  cautiously  with  a  blunt-pointed  bistoury, 
cutting  from  within  outward.  Sundry  meatotomes  have  been  devised, 
but  they  have  no  special  advantages.  The  meatus  must  be  so  enlarged, 
not  only  that  it  may  admit  instruments  of  the  proper  size,  but  that  it 
may  no  longer  dam  back  and  prevent  proper  drainage  of  urethral 
secretions.  The  urethra  itself  varies  in  caliber  in  different  individuals, 
as  Otis  long  ago  pointed  out  when  he  formulated  certain  rules  regarding 
its  size.  It  is  not  necessary  accurately  to  follow  rules  when  estimating 
the  size  of  sounds  which  a  urethra  may  take,  but  in  general  terms  there 
is  a  relation  between  the  caliber  of  the  urethra  and  the  circumference 
of  the  flaccid  penis.  For  instance,  a  penis  with  a  circumference  of 
three  inches  should  admit  a  urethral  sound  of  No.  30  French;  a  SJ-inch 
penis  should  admit  a  No.  35  French  sound;  a  circumference  of  4  inches 
should  call  for  a  No.  40  French  sound.  These  figures  are  approximate 
only,  but  will  serve  as  a  satisfactory  working  basis  for  the  surgeon. 

If  the  urethra  shows  anywhere  in  its  course  patches  of  ulceration  or 
granulation  when  inspected  with  the  endoscope,  the  surgeon  may 
touch  such  patches  with  4,  8,  or  12  per  cent,  silver  nitrate  on  a  swab. 
As  a  rule,  however,  dilatation  and  the  injection  of  strong  argyrol  render 
needless  such  touchings.  Chronic  infections  of  the  deeper  urethral 
glands  and  prostatic  sinuses  often  are  cured  by  the  argyrol  injections. 
However,  if  this  does  not  suffice,  especially  if  the  seminal  vesicles  and 
ejaculatory  ducts  are  involved,  the  surgeon  must  treat  the  patient  by 
massage  of  these  organs.  Massage  of  the  prostate  and  vesicles  is  an 
extremely  satisfactory  procedure  in  many  cases,  and  be  it  remembered 
that  a  thorough  rectal  examination  of  these  parts  should  be  made  in 
every  case  of  gleet.  In  order  most  effectively  to  employ  the  massage, 
have  your  patient  stand,  leaning  well  over  a  table  or  the  back  of  a  low 
chair,  wdth  his  knees  straight,  and  his  feet  about  18  inches  apart.  The 
surgeon  guards  his  finger  with  a  cot  and  introduces  it  slowly  and  care- 
fully into  the  rectum,  detecting  enlargements,  irregularities,  and  changes 
in  consistency  of  the  prostate ;  while  beyond  the  prostate  he  feels  for  the 
vesicles;  these  may  give  to  the  finger  the  sensation  of  a  thick  cord  or, 
if  there  be  extensive  periprostatic  involvement,  there  may  be  the  feeling 
of  a  general  boggy  enlargement  merely  of  the  whole  region.  The  sur- 
geon then  methodically  strips  down  with  his  finger  the  affected  area,  be- 
ginning at  the  highest  point  he  can  reach.  At  first  the  patient  may  com- 
plain of  pain  and  an  intense  desire  to  urinate,  but  it  is  surprising  often 
to  find  how  these  symptoms  may  subside  as  the  treatment  progresses, 
and  what  a  sense  of  relief  the  patient  experiences  after  the  treatment. 
Urine  passed  after  prostatic  massage  will  contain  pus,  shreds,  and  semen 


444  GENITO-URINARY    ORGANS 

generally.  Some  patients  are  free  from  sym])toms  after  two  or  three 
such  treatments,  while  other  patients  need  many  more.  It  is  well  not  to 
massage  the  prostate  and  vesicles  more  than  two  or  three  times  a  week, 
and  I  rarely  give  them  a  treatment  of  more  than  five  or  ten  minutes  at  a 
time.  Nearly  all  cases  of  chronic  gonorrhea  are  benefited  by  a  i)rostatic 
massage.  This  measure  is  the  most  important  addition  of  recent  years 
to  the  therapeutics  of  gleet.  Eugene  Fuller  advises  and  practises  enu- 
cleation of  the  vesicles  through  the  rectum  in  cases  of  vesiculitis,  but 
I  have  not  yet  encountered  a  case  in  which  this  seemed  necessary. 

Such,  in  brief  outline,  are  the  general  principles  on  which  we  treat 
chronic  gonorrhea.  The  vital  cjuestion  remains:  \^'hen  is  the  patient 
cured?  Whitney  gives  a  rule  which  is  satisfactory  ■}  "  When  there  is  no 
longer  a  discharge,  when  the  shreds  contain  neither  pus,  gbnococci, 
nor  a  large  amount  of  epithelium;  and  when,  furthermore,  after  produc- 
ing a  discharge  by  silver  nitrate,  no  organisms  are  present;  also  when, 
after  alcoholic  or  sexual  excess,  no  discharge  appears." 

THE  GENITAL   LESIONS   OF   SYPHILIS 

The  genital  lesions  of  S3'philis  rank  with  those  conditions  we  have 
just  considered.  I  shall  not  in  this  book  discuss  in  detail  the  great 
subject  of  syphilis,  referring  the  reader  to  special  treatises  and  to  the 
large  systems  of  surgery.  I  shall  mention  here  the  syphilitic  lesions  of 
the  external  genitals,  and  shall  say  a  word  regarding  the  initial  treat- 
ment of  the  disease. 

As  gonorrhea  is  due  to  the  diplococcus  of  Neisser,  so  it  now  seems  to 
be  proved  beyond  much  question  that  syphilis  is  due  to  the  treponema 
(Spirochcta  pallidum,  first  observed  by  Schaudinn  and  Hoffmann). 
Ordinarily,  the  writers  on  syphilis  describe  three  periods  of  the  disease — 
primary,  secondary,  and  tertiary.  More  exact  recent  studies  show  that 
these  divisions  are  more  or  less  artificial,  and  that  the  three  periods  often 
overlap  and  run  into  one  another. 

(1)  The  period  of  primary  incubation — the  time  elapsing  between 
inoculation  and  the  appearance  of  the  initial  lesion  (chancre) — averages 
three  weeks. 

(2)  The  period  of  secondary  incubation — the  time  elapsing  from 
the  appearance  of  the  chancre  to  the  development  of  cutaneous  and 
mucous  membrane  lesions — averages  six  weeks.  The  secondary  period 
lasts  about  two  years  unless  the  disease  be  cured  by  treatment. 

(3)  The  tertiary  period  begins  usually  about  three  years  from  the 
time  of  the  initial  lesion,  and  lasts  indefinitely,  depending  largely  on  the 
efficiency  of  treatment.  In  this  period  gummata  develop,  as  well  as  the 
characteristic  lesions  of  the  bones  and  of  the  nervous  system. 

In  the  great  majority  of  cases  chancre  is  the  first  lesion  of  syphilis. 
It  is  a  contact  sore  which  appears  in  man  usually  on  the  prepuce,  some- 
times on  the  glans.     At  first,  it  seems  a  trifling  abrasion.     Gradually 

1  C.  M.  Whitney,  The  Etiology  and  Modern  Methods  of  Treatment  of  Clironic 
Urethritis,  Boston  Med.  and  Surg.  Jour.,  July  21,  1904. 


THE   GENITAL    LESIONS   OF   SYPHILIS  445 

and  painlessly  it  becomes  larger,  always  surrounded  by  a  characteristic 
induration.  It  must  be  always  distinguished  from  the  so-called  "  soft 
chancre''  (chancroid).  The  true  chancre  is  commonly  spoken  of  as 
"  hard  chancre."  The  hardness  or  induration  is  characteristic  of  the 
true  syphilitic  lesion.  The  hardness  surrounds  an  ulcerating  disk,  which 
varies  in  apparent  thickness,  sometimes  appearing  as  a  sheet  of  tissue- 
paper,  again  as  thick  as  blotting-paper.  It  rarely  becomes  larger  in 
circumference  than  the  little  finger-nail.  (The  examining  surgeon  lifts 
up  the  whole  lesion  with  his  thumb  and  forefinger  in  order  to  ascertain 
its  extent  and  consistency.)  The  induration  of  chancre  remains  for 
from  one  to  six  months  after  the  ulcer  is  healed. 
Chancre  has  the  following  nine  characteristics: 

(1)  Incubation  (time  elapsed  from  contact  exposure  to  appearance 
of  sore)  for  from  twelve  to  fifty  days — average,  three  weeks. 

(2)  The  sore  is  indolent,  discomfort  slight,  discharge  slight. 

(3)  The  form  is  rounded. 

(4)  The  sore  is  indurated  and  induration  may  precede  ulceration. 

(5)  There  is  a  painless  enlargement  of  the  adjacent  lymph-nodes  in 
the  groin. 

(6)  The  chancre  persists  in  spite  of  local  treatment. 

(7)  Scrapings  from  the  sore  will  be  found  to  contain  spirochetse. 

(8)  The  sore  heals  as  a  result  of  constitutional  treatment  with 
mercury. 

(9)  The  sore  is  single  in  from  SO  to  90  per  cent,  of  all  cases. 

We  are  discussing  briefly  genital  chancres  only,  but  the  reader  must 
remember  that  a  chancre  may  develop  on  any  surface  of  the  body, 
especially  near  the  mucocutaneous  borders. 

Note  here,  in  contradistinction,  the  following  seven  characteristics 
of  chancroid: 

(1)  Rapid  development  after  exposure  (two  or  three  days). 

(2)  Two  or  more  lesions. 

(3)  Pustular  or  ulcerating  from  the  start. 

(4)  Destructive  and  inflammatory  in  type. 

(5)  Produces  auto-inoculations — causing  similar  lesions  on  surfaces 
with  which  the  discharge  comes  in  contact. 

(6)  Soft,  no  surrounding  induration. 

(7)  Early,  painful,  inflammatory  lymph-nodes  ("  buboes")- 
Chancroid  is  due  to  a  specific  streptobacillus,  described  by  Ducre 

as  short  and  thick,  with  rounded  ends,  somewhat  dumbbell  shaped. 

We  shall  concern  ourselves  here  with  the  treatment  of  three  lesions 
only — chancre,  bubo,  and,  incidentally,  chancroid. 

The  treatment  of  the  primary  lesion — chancre — has  been  the  sub- 
ject of  active  discussion.  Many  experienced  surgeons  maintain  that  the 
chancre  should  be  excised  so  soon  as  it  is  discovered,  while  a  coincident 
constitutional  treatment  should  be  begim  at  once.  The  tendency  at 
Harvard,  influenced  largely  by  the  veteran  James  C.  White,  follows 
quite  another  course.  We  believe  that  the  early  constitutional  treat- 
ment of  syphilis  is  frequently  founded  on  errors  in  diagnosis ;  that  a  posi- 


446  GENITO-URINARY  ORGANS 

tive  diagnosis  of  syphilis  cannot  be  made  until  skin-lesions  appear; 
and  that  to  institute  early  constitutional  treatment  frequently  may 
serve  to  abort  skir  ns,  so  that  in  a  given  case  no  positive  diagnosis 

ever  can  be  made.  vcrtheless,  the  patient  is  doomed  to  go  through 

life  with  the  stigma  of  syphilis  upon  him,  when  indeed  he  may  never 
have  had  syphilis.  We  have  seen  no  damage  result  from  delaying  con- 
stitutional treatment — the  delay  rarely  lasts  longer  than  four  weeks. 

\A'hile  waiting  to  begin  constitutional  treatment,  keep  the  parts 
clean  with  soap  and  water,  dusting  the  chancre  with  a  clean  drying 
powder,  such  as  bismuth  subgallate  or  powdered  calomel.  Build  up  the 
patient's  general  condition  with  tonics  and  out-of-door  life. 

So  soon  as  the  diagnosis  of  syphilis  is  confirmed  by  the  appearance  of 
skin-lesions,  begin  constitutional  treatment  with  mercury — either 
internally,  in  pill  form,  externally,  by  inunctions,  or  by  hypodermic 
injection.  Undoubtedly  inunctions  are  the  most  effective  if  they  are 
persistently  employed,  but  they  are  an  intolerable  annoyance,  and  few 
persons  can  be  founfl  to  use  them  faithfully. 

Treatment  by  Mouth. — My  custom  is  to  begin  with  a  pill  of  the  prot- 
iodid  of  mercury,  gr.  ^  by  mouth,  three  times.  After  this  dose  I  give 
one  more  pill  daily  until  the  j^atient  begins  to  show  symptoms  of  gastric 
or  intestinal  disturbance.  By  this  time  he  may  be  taking  10,  12,  or  15 
pills  daily.  If,  for  example,  his  maximum  dose  is  12,  we  conclude  that 
he  can  take  one-half  of  that  dose  continuously.  We,  therefore,  prescribe 
6  pills  daily  to  be  taken  for  many  months — usuallj'  for  from  twelve  to 
twenty-four  months.  Under  this  treatment  the  syphilitic  lesions  disap- 
pear in  a  very  few  days,  and  most  patients  regain  symptomatic  health 
promptly. 

Treatment  by  Inunctions. — An  excellent  mercury-bearing  ointment  is: 

I^.     Ung.  hydrarg., 

Ung.  petrolati  carbolat aa   oj- 

M.  Divide  in  8  parts,  placing  each  in  wax  paper  or  a  cachet. 
SiG. — Use  one  as  a  surface  apphcation  immediately  after  a  hot  bath. 

The  patient  must  take  pains  not  to  cause  excessive  skin  irritation  by  the 
use  of  ointments.  He  should  rub  in  the  ointment  for  five  minutes,  in  a 
new  spot  every  day,  choosing  surfaces  covered  by  delicate  skin — the 
inside  of  the  thigh,  the  arm,  the  chest  beneath  the  axilla. 

Treatment  by  Hypodermic  Injections. — Hypodermic  injections  are 
effective,  but  their  employment  is  an  intolerable  nuisance  to  the  patient, 
who  must  visit  the  surgeon  frequently  to  receive  them.  Sometimes 
they  are  painful.  They  should  be  given  deep  into  the  lumbar  and  gluteal 
muscles.  The  ordinary  dose  is  mercury  bichlorid,  gr.  -j^-  to  ^  daily. 
Edward  Martin's  excellent  rule  is  to  repeat  this  in  appropriate  doses 
until  the  syphilitic  symptoms  disappear,  after  which  time  it  is  continued 
in  series  of  six  doses,  with  intervals  of  six  days'  rest  for  the  first  year; 
and  in  series  of  three  doses,  with  intervals  of  nine  days'  rest  for  the  second 
year;  the  quantity  being  increased  or  diminished  in  accordance  with  the 
clinical  indications. 


INJURIES   OF  THE   PENIS  447 

Here  is  a  useful  formula: 

R.     Ilydnirg.  l)iclilor.  corros .   gr.  4.8 

8()dii  chloric! gr.  3.5 

Aqua   destillat .    5 j- 

SiG. — 10  to  30  minims,  hypodermically. 

The  treatment  of  chancroid  differs  materially  from  the  treatment 
of  chancre.  Chancroid  must  be  attacked  vigorously.  If  it  is  superficial 
and  of  moderate  extent,  cauterize  it  thoroughly  with  pure  carbolic  acid 
after  careful  preparation  of  the  parts  and  the  induction  of  anesthesia, 
either  local  or  general.  If  the  ulceration  is  deep  and  involves  the  skin 
and  prepuce  extensively,  one  may  advantageously  employ  the  Paquelin 
cautery.  Often,  however,  cauterization  is  impossible  on  account  of 
the  objections  of  the  patient  and  the  extent  of  the  lesion.  In  most 
cases  wet  dressings  will  be  found  comfortable,  and  nearly  always  in 
case  of  extensive  chancroid  the  patient  should  be  kept  quiet  in  bed. 
I  have  the  ulcer  cleaned  up  twice  daily  with  gentle  applications  of 
hydrogen  dioxid,  half  strength,  while  the  penis  is  kept  soaking  contin- 
uously in  a  weak  corrosive  sublimate  poultice,  made  up  of  strips  of 
gauze,  wrung  out  of  corrosive  subhmate,  1 :  5000. 

Vigorous  constitutional  tonic  treatment  with  iron  and  an  out-of- 
doors  life  are  important.  As  yet  I  have  seen  no  benefit  from  the  use 
of  opsonic  vaccines. 

The  adenitis  of  the  groin  (bubo)  resulting  from  chancroid  is  often 
vicious.  A  mass  of  broken-down  lymph-nodes  may  develop  in  a  few 
days  from  the  onset  of  the  disease.  If  the  enlarged  nodes  are  discovered 
early,  before  suppuration  occurs,  shave  the  parts  and  apply  daily  an 
ointment  composed  of  mercury  iodid,  10  parts;  petrolati,  90  parts. 
Later,  in  case  the  mass  suppurates,  open  it  extensively,  paint  the 
interior  of  the  wound  with  tincture  of  iodin,  and  pack  it  with  iodoform 
gauze. 

Chancroids  with  their  associated  buboes  often  cause  pronounced 
constitutional  disturbance.  The  patient  seems  very  sick.  His  tem- 
perature may  run  high  and  his  appearance  may  be  typhoidal  even. 
Keep  him  in  bed,  and  treat  him  as  a  sick  man  until  his  temperature  is 
normal  and  his  wounds  are  granulating. 

INJURIES  OF  THE  PENIS 

Injuries  of  the  penis  sometimes  occur  as  the  result  of  blows  and  falls 
astride.  These  injuries  may  cause  tearing  of  the  urethra,  the  corpus 
spongiosum,  and  the  corpora  cavernosa,  and,  according  to  the  severity 
of  the  injury,  may  or  may  not  call  for  operative  treatment.  In  the  case 
of  rupture  of  the  urethra  the  canal  must  be  cut  down  upon  through  the 
corpus  spongiosum  and  sutured;  and  it  is  wise,  generally,  to  fasten  a 
catheter  into  the  bladder,  through  the  urethra,  to  remain  in  place  during 
the  first  week  of  convalescence.  Such  a  ruptured  urethra  may  give  rise 
to  extravasation  of  blood  and  urine,  extensive  infiltration  and  sloughing 
of  the  tissues,  enormous  swelling,  and  ecchymoses.     A  urethra  ruptured 


448  GEXITO-URIXARY    ORGANS 

anterior  to  the  trianfjular  lifiamcnt  and  cut-off  muscle,  produces  an 
extravasation  into  the  scrotum,  penis,  and  thighs.  A  urethra  ruptured 
in  the  posterior  portion  gives  rise  to  extravasation  into  the  perineum, 
buttocks,  groins,  and  abdominal  wall.  As  I  said  in  describing  extra- 
peritoneal rupture  of  the  l)ladder,  these  extravasations  must  be  searched 
out  with  the  knife;  all  collections  must  be  evacuated,  the  damaged 
urethra  repaired,  and  hemorrhage  checked.  Rupture  of  the  corpora 
merely  must  be  treated  by  rest,  ice-bags,  and  the  control  of  hemor- 
rhage. 

GENITAL  HERPES 

Genital  her]3es  is  an  cru])tion  on  the  prepuce  and  behind  the  corona. 
It  appears  as  a  series  of  vesicles  and  is  multiple.  The  patients  are  often 
much  alarmed,  and  ask  to  have  the  condition  differentiated  from  chancre 
and  chancroid.  Herpetic  vesicles  are  multiple,  small,  soft,  and  without 
Ij'mphatic  enlargement;  chancre  is  single,  with  an  indurated  base,  ulcer- 
ating, and  with  lymphatic  enlargements;  chancroid  is  multiple  gener- 
alh',  ulcerating  and  with  a  soft  base,  and  generally  with  lymphatic 
enlargements  (bubo).  Treat  herpes  by  cleanliness  and  the  application 
of  borax  and  starch,  aristol,  or  some  other  simple  drj'ing  powder. 

VENEREAL   WARTS 

Venereal  warts  or  verruca  are  small  warty  appearances  upon  the 
glans  or  prepuce — a  hypertrophy  of  the  papillae,  proliferation  of  the 
connective  tissue,  and  increased  vascularity.  The}-  may  appear  also 
on  the  scrotum  and  thighs.  When  on  mucous  surfaces,  they  are  moist 
and  soft;  when  on  the  skin,  they  are  dry  and  hard.  They  may  be  single 
or  multiple,  and  may  grow  to  a  considerable  size.  They  may  ulcerate 
and  break  down,  giving  rise  to  a  discharge  and  a  foul  odor.  You  must 
differentiate  these  warts  from  the  flat  condylomata  of  s}T3hihs.  The 
condylomata  are  of  late  appearance  and  of  slow  growth;  they  may  be 
of  wide  extent  and  are  less  likely  to  slough  and  become  foul  than  are 
warts.  Epitheliomata  also  must  be  distinguished,  but  epitheliomata, 
appearing  in  elderly  persons,  are  of  very  slow  growth,  and  their  nature 
may  be  ascertained  b}^  the  examination  of  a  microscopic  section.  The 
cure  of  venereal  warts  generally  is  an  easy  matter.  They  may  be 
aborted  when  seen  early,  by  thorough  washing,  three  or  four  times  a  day, 
wath  a  1 :  1000  bichlorid  .solution,  and  dusting  with  calomel.  The  best 
treatment  when  they  are  at  all  advanced  is  to  cocainize  the  parts,  thor- 
oughl}'  to  curet  away  the  growths,  and  dress  the  wounds  with  aristol. 

Horns  sometimes  grow  from  the  genitals,  and  J.  B.  Blake  recently 
has  reported  the  case  of  an  extraordinary  horn,  half  the  size  of  the  little 
finger,  springing  from  the  dorsum  of  the  glans.^ 

CIRCUMCISION 

The  circumcision  of  infants  is  a  useful  old  custom  which  we  are 
returning  to  in  these  days.     Parents  often  ask  the  purpose  of  this  treat- 
1  J.  B.  Blake,  Boston  Med.  and  Surg.  Jour.,  1907. 


CIRCUMCISION 


449 


ment.  In  the  case  of  a  child  with  a  long  prepuce  of  narrow  opening, 
which  cannot  be  drawn  back  over  the  glans  after  faithfid  effort,  circum- 
cision anticipates  many  troubles  for  the  growing  boy.  It  renders 
possible  proper  cleanliness;  it  prevents  the  collection  of  smegma  beneath 
the  prepuce;  and  smegma  is  an  irritant  which  leads  the  child  to  masturba- 


Fig.  273. — Circumcision — step  1. 

tion,  to  nocturnal  incontinence,  and  may  set  up  irritating  inflammations 
with  phimosis.  Circumcision  properly  done  is  a  comforting  operation. 
Circumcision  improperly  done  produces  an  organ  almost  deformed. 
Cutting  off  too  much  skin  results  in  a  painful  stripping  of  the  glans; 
cutting  off  too  little  skin  leaves  absurd  flapping  dog's-ears.     Don't 


Fig.  274. — Circumcision — step  2. 

operate  with  cocain  anesthesia  in  the  case  of  an  infant.  Use  ether,  for 
the  patient  should  be  properly  anesthetized  and  the  surgeon  should 
be  enabled,  with  painstaking  care,  to  accompHsh  this  little  operation. 
Draw  out  the  prepuce  well  beyond  the  glans  and  catch  its  edge  on 
either  side  of  the  middorsal  line  with  snap  forceps;  then,  while  hold- 
ing it  stretched,  slit  up  the  median  line,  as  far  as  the  corona,  avoid- 

29 


450  GENITO-URINARY   ORGANS 

ing  any  radicles  of  the  lar<;e  dorsal  vein.  Then  trim  off  the  resulting 
circular  flap,  taking  pains  not  to  make  it  too  short.  Tie  all  bleeding 
points  with  fine  catgut,  and  sew  together  the  cut  mucocutaneous  flaps 
incircling  the  glans  with  a  fine,  plain,  continuous  catgut  stitch.  If 
you  work  with  care  and  deliberation,  the  wound  should  heal  promptly 
in  four  or  five  days.  Rough  work  will  give  rise  to  ecchymosis  and  pain- 
ful swellings.  There  is  no  use  in  attempting  to  apply  a  permanent 
dressing,  especially  in  the  case  of  an  infant,  for  dressings  must  be 
removed  when  the  patient  urinates,  and  at  the  best  a  baby's  dressing  is 
sure  to  become  soaked.  I  have  the  patient  wear  a  diaper,  with  a  wad  of 
sterilized  gauze  wrapped  about  the  penis.  With  every  act  of  urination 
the  gauze  is  removed,  the  penis  gently  sprayed  off  with  warm  sterilized 
water,  and  fresh  gauze  and  diaper  applied. 

The  circumcision  of  an  adult  ma}'  be  done  under  cocain  anesthesia. 
The  man  should  be  directed  to  lie  still  for  four  or  five  days  at  least,  as  the 
irritation  of  walking  about  almost  certainly  leads  to  delayed  wound 
healing.     The  figures  illustrate  an  excellent  method. 

CANCER  OF  THE  PENIS 

Cancer  of  the  penis  ^  is  a  rather  frequent  tumor  of  indolent  growth  for 
malignant  disease.     Usually  it  appears  first  as  a  wart  on  the  glans  or 


Fig.  275. — Carcinoma  of  tlie  penis. 

prepuce,  and  one  finds  it  in  men  in  middle  life,  commonly  between  the 
ages  of  fifty  and  sixty.     In  its  course  cancer  destroys  the  penis  if  left 

*  I  refer  the  reader  to  an  extremely  illuminating  article  on  this  subject  by  J.  D. 
Barney,  Ann.  Surg.,  December,  1907. 


FOREIGN  BODIES  IN  THE  URETHRA  451 

untreated.  It  develops  into  an  ulcerating  area  or  a  considerable  cauli- 
flower growth;  it  may  involve  the  urethra/  giving  rise  to  fistula,  and  it 
spreads  to  the  inguinal  and  lumbar  lymph-nodes  even.  As  I  said  in 
speaking  of  warts,  cancer  must  be  distinguished  from  vermes,  herpes, 
and  chancre. 

The  only  treatment  is  operative,  and  that  is  useless  if  considerable 
metastases  have  developed.  The  operation  is  amputation  of  the 
penis.  Bigelow  used  to  teach  that  the  way  to  amputate  the  penis  was 
to  cut  it  off  at  a  single  stroke  and  sew  the  loose  outer  skin  to  the  stump 
of  the  urethral  mucosa.  A  much  better  operation  is  the  combined 
dorsal  flap  and  circular  method.  This  requires  a  little  careful  dissecting. 
A  flap  of  considerable  length  is  taken  from  the  dorsum,  and  the  penis  is 
amputated  at  the  root  of  the  flap,  the  corpus  spongiosum  being  left  a 
quarter  of  an  inch  longer  than  the  corpora  cavernosa.     The  dorsal 


Fig.  276. — Amputation  of  the  penis. 

flap  is  then  drawn  over  the  stump  and  stitched  into  place  on  the  oppo- 
site side.  A  hole  is  excised  from  the  flap  opposite  the  urethral  stump. 
Through  this  hole  the  urethra  is  drawn  and  is  fastened  to  the  edges  of  the 
hole  in  the  flap. 

In  early  cases  amputation  saves  the  patient's  life,  but  in  far  too 
many  instances  recurrence  occurs  in  the  penis  or  in  the  lymph-nodes. 

FOREIGN  BODIES  IN  THE  URETHRA 

Foreign  bodies  occasionally  are  found  in  the  urethra,  and  serious 
injuries  from  them  may  result,  with  obstruction  of  the  stream,  ulcera- 
tion of  the  canal,  and  the  formation  of  abscesses  and  fistulse.  Children 
and  persons  with  depraved  instincts  frequently  are  known  to  insert 

1  J.  D.  Barney,  Cancer  of  the  Male  Urethra,  Boston  Med.  and  Surg.  Jour.,  Decem- 
ber 12,  1907. 


452  GENITO-URINARY   ORGANS 

foreign  bodies  into  the  urethra,  and  all  sorts  of  curious  articles  have 
been  found  there.  The  bodies  may  be  expelled  l)y  the  stream  of  urine; 
or  one  may  be  obliged  to  search  for  them  with  the  endoscope,  and  to 
extract  them  with  fine  grasping-forceps;  or  one  may  have  to  cut  down 
upon  them  from  without  and  open  the  urethra  to  extract  them.  In  the 
last  case  sew  up  with  fine  catgut  the  urethra,  and  fasten  into  the  bladder 
an  in-lying  catheter  for  four  or  five  days. 

Calculus  of  the  urethra  may  form  about  a  foreign  body,  or  a 
urinary  calculus  from  higher  up  may  lodge  in  the  urethra.  Extract  it 
in  like  manner  as  you  would  a  foreign  body. 

PARA-URETHRAL  ABSCESS 

Para-urethral  abscess  may  form  as  the  result  of  ulceration  by  a 
foreign  body  in  the  urethra  or  as  a  complication  of  gonorrhea.  Its 
presence  is  readily  detected  by  the  touch.  Sometimes  it  may  be  opened 
with  a  fine-pointed  knife  or  urethrotome  from  within  the  urethra.  In 
any  case  the  patient  should  be  put  to  bed,  and  careful  aseptic  treat- 
ment with  urotropin  and  irrigation  should  be  instituted. 

STRICTURE  OF  THE  URETHRA 

Stricture  of  the  urethra  should  be  ranked  with  venereal  disease  as 
one  of  the  commonest  afflictions  know^n  to  man.  Writers  tell  of  con- 
genital and  acquired  strictures.  In  fact,  congenital  strictui'es  are 
extremely  rare,  except  for  that  congenitally  narrow  meatus  of  which 
I  have  spoken;  but  acquired  stricture  is  common  enough,  and  there 
are  two  ordinary  methods  of  acquiring  it — by  an  injury  or  by  a  gonor- 
rhea. In  general  terms  a  stricture,  in  whatever  way  acquired,  arises 
from  the  formation  of  exudate  or  scar  tissue  pressing  upon  or  actually 
involving  the  urethral  mucosa. 

Traumatic  stricture  occurs  usually  in  the  perineum,  though  it  may 
occur  elsewhere,  and  especially  from  the  ulceration  of  a  foreign  body. 
The  common  cause  of  traumatic  stricture,  however,  is  from  a  fall  astride 
of  some  such  object  as  a  fence,  with  a  resulting  rupture  or  biiiising  of 
the  perineum,  often  involving  the  bulbomembranous  urethra.  Such 
a  stricture  as  this  may  cause  slight  and  temporary  disturbance  only,  or 
may  be  a  life-long  affliction.  As  the  wound  heals  and  the  scar  contracts, 
the  caliber  of  the  urethra  may  be  greatly  narrowed  or  obliterated  even. 
If  the  patient  is  seen  immediately  after  the  injury,  and  if  there  be  such 
evidence  of  laceration  of  the  urethra  as  complete  retention,  extravasa- 
tion, or  bloody  urine,  the  surgeon  should  etherize  the  patient;  place  him 
in  the  lithotomy  position  in  a  good  light;  pass  a  staff  or  sound  as  far  as 
possible  into  the  virethra;  cut  down  upon  it  through  the  perineum;  con- 
trol the  hemorrhage;  seek  the  torn  parts  of  the  urethra;  sew  them  to- 
gether with  fine  catgut  (No.  00) ;  and  fasten  a  catheter  into  the  bladder. 
Such  prompt  treatment  will  nearly  always  remedy  permanently  the 
damage.  On  the  other  hand,  if  urgency  is  not  apparent  and  the  injury 
is  treated  by  palliative  measures,  and  the  wound  is  allowed  to  heal  in 


STRICTURE    OF   THE    URETHRA 


453 


the  natural  manner,  it  heals  with  a  resulting  stricture  often.  The  con- 
sequences of  stricture  I  shall  speak  of  at  more  length  when  describing 
that  form  which  is  due  to  gonorrhea;  suffice  it  to  say  that  in  the  case  of 
traumatic  stricture  the  patient's  symptoms  are  wont  to  be  progressive, 
often  running  over  years  before  he  consults  the  surgeon.  He  will  then 
tell  of  a  gradual  narrowing  of  the  stream,  of  difficulty  in  micturition, 
accompanied  often  by  burning  and  pain,  sometimes  of  frequency 
suggesting  an  associated  cystitis.  Sometimes  there  will  be  found  a 
small,  thick-walled  bladder,  at  other  times  a  thin-walled  distended 
bladder. 


Fig.  277. — Perineal  urethrotomy,  cutting  on  the  staff. 

The  treatment  of  traumatic  stricture  is  imperative  and  is  by  operation. 
The  patient  is  placed  in  the  lithotomy  position.  A  staff  is  passed  down 
to  the  stricture  and  is  cut  down  upon  through  the  perineum.  In  these 
cases,  cutting  operations  from  within  by  the  urethrotome  are  miproper, 
though  a  gradual  dilatation  with  sounds  of  a  traumatic  stricture  is  suit- 
able, when  sounds  can  be  passed  without  violence.  Unfortunately ,_  how- 
ever, it  may  be  impossible  to  pass  any  instrument  through  the  stricture 
into  the  bladder,  because  the  course  of  the  stricture  often  is  extremely 
tortuous,  even  if  it  is  not  too  narrow  to  admit  the  smallest  instrument. 


454  GENITO- URINARY   ORGANS 

The  operation  of  pcriyical  section  is  our  usual  resort,  therefore,  and  this 
may  prove  to  be  an  o]>erati()n  of  extreme  difficulty.  An  assistant  must 
hold  the  staff  in  the  urethra  so  that  the  staff  bulges  the  i)enneum.  The 
surgeon  then  cuts  down  upon  it,  opens  the  urethra,  and  secures  its  edges 
with  retention  stitches.  Usually  there  is  a  good  deal  of  bleeding,  which 
obscures  the  field  if  the  hemorrhage  be  not  controlled.  The  surgeon 
next  endeavors  to  discover  the  uninjured  proximal  end  of  the  urethra. 
This  may  necessitate  a  tedious  and  extensive  dissection.  If  the  scar 
tissue  be  insignificant  in  extent,  it  may  be  cut  away,  the  proximal 
urethral  stump  discovered,  and  an  end-to-end  urethral  junction  estab- 
lished. The  difficulty  is  to  find  the  proximal  end.  There  are  a  number 
of  maneuvers  in  technic  which  help  to  accomplish  this  purpose.  One 
is  to  discover  and  identify  an  important  artery — a  branch  of  the  artery 
of  the  bulb,  which  runs  forward  along  the  course  of  the  urethra  and 
close  to  that  canal.  If  one  can  isolate  this  artery,  one  may  be  sure  that 
he  is  in  close  proximity  to  the  sovight-for  urethra.  Again,  the  elusive 
urethra  may  be  discovered  by  forcing  urine  through  it  from  the  bladder, 
by  pressure  on  the  bladder  above  the  pubes.  To  this  end  the  surgeon 
should  instruct  the  patient  not  to  empty  his  bladder  before  the  operation. 
Often  no  special  difficulty  is  encountered,  and  almost  at  once,  on  opening 
the  perineum,  the  surgeon  finds  the  urethra  and  passes  a  probe,  director, 
or  Teale's  gorget  through  it  into  the  bladder.  When  once  you  have 
isolated  the  proximal  portion  of  the  urethra,  do  not  lose  it.  The  fur- 
ther treatment  of  the  stricture  is  not  especially  difficult.  If  the  two 
portions  of  the  urethra  can  be  brought  together  and  sutured,  the  prob- 
lem is  solved  at  once.  If  this  cannot  be  done,  the  surgeon  should  pass  a 
large  catheter  or  drainage-tube  through  the  perineal  wound  into  the 
bladder,  and  fasten  it  there  for  temporary  drainage.  At  the  end  of 
five  or  six  days,  when  granulations  have  begun  to  appear,  the  drainage 
catheter  should  be  removed,  and  sounds  of  a  proper  size  should  be 
passed  every  other  day  through  the  penile  urethra  and  into  the  bladder. 
The  success  of  this  maneuver  in  reestablishing  the  normal  passage  de- 
pends upon  the  fact  that  the  urethral  mucosa  has  a  curious  capacity 
for  bridging  space,  as  we  see  illustrated  in  the  restoration  of  the  urethra 
after  it  has  been  torn  out  in  the  operation  of  suprapubic  prostatectomy. 

As  a  rule,  the  convalescence  from  perineal  section  is  eas}^  and  sur- 
prisingly short.  The  perineal  fistula  closes  in  two  or  three  weeks,  and 
the  urethra  soon  takes  up  its  proper  function.  It  is  well  to  pass  a  sound 
occasionally,  perhaps  once  or  twice  a  month,  for  several  months  after  the 
operation,  in  order  to  provide  against  recontraction  of  the  canal.  In 
some  rare  cases  a  permanent  cure  is  not  established,  owing  to  the  wide 
damage  caused  by  the  original  traumatism.  In  such  cases  the  patient's 
comfort  through  the  rest  of  his  life  will  depend  upon  the  occasional 
passage  of  a  sound. 

Acquired  stricture,  the  result  of  gonorrhea,  may  be  inflammatory 
and  temporary  in  exceptional  cases,  but  is  usually  due  to  permanent 
tissue  changes — organic  stricture.  There  is  also  the  spasmodic  stric- 
ture, the  result  of  a  contraction  of  the  circular  muscle-fibers  of  the 


STRICTURE   OF  THE    URETHRA  455 

urethra  or  of  the  compressor  urethrae.  This  spasmodic  stricture  is  a 
reflex  affair  conmionly.  It  may  be  a  neurosis;  it  maybe  due  to  terror, 
anxiety,  or  embarrassment,  or  it  may  be  due  to  posture,  such  as  lying 
on  the  back.  I  have  already  discussed  it  when  speaking  of  diseases  of 
the  female  genital  organs.  Analogous  conditions  exist  in  the  male. 
Usually  the  spasm  may  be  relaxed  by  hot  applications  over  the  bladder 
and  on  the  perineum,  by  immersion  in  a  warm  bath,  often  by  the  sound 
of  trickling  water;  if  necessary,  by  the  use  of  small  doses  of  opium,  pref- 
erably in  suppository  form  (powdered  opium,  1  grain),  and  if  these 
measures  fail,  by  the  catheter. 

Inflammatory  stricture  is  a  rare  condition,  and  some  authorities 
have  doubted  its  existence,  attributing  the  state  to  a  previously  existing 
organic  stricture.  I  have  convinced  myself,  however,  from  experience 
with  a  variety  of  cases,  that  inflammatory  stricture,  a  swelling  of  the 
urethral  mucosa,  may  sometimes  exist  so  as  to  cause  narrowing  of  the 
stream  or  its  complete  obstruption  even  without  relation  to  organic 
stricture.  The  obstruction  of  inflammatory  stricture  may  be  easily 
overcome  by  immersion  in  the  warm  bath,  or  if  that  does  not  succeed, 
by  a  small  soft-rubber  catheter. 

Organic  stricture  from  gonorrhea  is  the  condition  with  which  we  are 
concerned  here;  and  organic  stricture  of  gonorrheal  origin  is  the  stricture 
of  daily  experience.  A  long-standing  gonorrhea  sets  up  and  leaves  be- 
hind it  in  the  mucosa  areas  of  ulceration,  or  chronic  injections  and  thick- 
enings of  the  mucous  lining.  At  the  affected  points,  infective  agents 
penetrate  the  mucosa  and  involve  the  para-urethral  structures.  Har- 
rison has  said  that  urine  actually  penetrates  through  the  mucosa,  but 
this  is  not  necessary  for  the  establishment  of  an  inflammatory  exudate. 
This  exudate  encroaches  from  without  upon  the  lumen  of  the  urethra  and 
causes  narrowing  of  that  canal.  In  process  of  time  cicatricial  tissue 
takes  the  place  of  the  exudate,  with  a  resulting  permanent  contraction 
of  the  urethra — by  cicatricial  tissue  which  may  or  may  not  involve 
the  urethral  canal  itself.  The  reader  will  perceive,  therefore,  that  the 
extent  and  nature  of  the  stricture  may  vary  greatly.  There  may  be  the 
rare,  single,  encircling  stricture;  but  more  commonly  the  stricture  is 
rather  diffuse,  and  frequently  there  are  multiple  strictures.  The 
urethral  canal  may  present  a  mere,  smooth  narrowing,  or  it  may  be  throw 
into  folds  and  pockets  so  that  the  urine  must  pass  in  a  labyrinthine 
course.  From  these  conditions  the  reader  will  see  that  the  treatment 
of  stricture  may  be  a  simple  undertaking  or  may  be  extremely  com- 
plicated. 

The  symptoms  of  stricture  vary  with  the  character  and  degree  of  the 
contraction.  Usually  the  patient  will  give  a  history  running  back  over 
about  two  years.  He  tells  of  frequency  of  micturition  and  of  narrow- 
ing of  the  stream,  which  may  be  double,  flat,  or  spraj'-like,  or  may  be 
passed  in  drops  only.  In  advanced  stricture  there  is  diminished  ex- 
pulsive power  and  dribbling  at  the  end  of  urination.  Occasionally  there 
is  scalding.  Rarely  there  is  that  retention  of  which  I  have  treated  in 
Chapter  XIV.     During  the  act  of  micturition  there  is  wont  to  be  vesical 


456  gp:nito-uri.\auy  organs 

tenesmus.  Sometimes  there  is  a  constantly  present  slight  urethral 
discharge  of  nuicoid  material;  often  the  act  of  coitus  is  incomplete,  and 
the  patient  may  suiYer  from  a  condition  of  general  debility  induced 
especially  by  involvement  of  the  bladder  and  kidneys  and  an  extensive 
breakdown  of  the  urinary  apparatus. 

In  explanation  of  some  of  the  above  symptoms  the  reader  should 
acquire  a  further  knowledge  of  the  nature  of  stricture  and  its  sequelaj 
and  of  the  complicated  processes  which  it  sets  up.  Bearing  in  mind  that 
the  normal  urethra  is  a  collapsible,  elastic  tube,  through  which  urine 
flows  without  obstruction,  and  in  which  the  pressure  is  everywhere 
equal  during  micturition,  one  perceives  that  stricture  alters  this  normal 
condition — stricture  of  the  largest  caliber  even.  \Miencver  there 
is  the  slightest  obstruction  to  the  stream  of  urine,  the  pressure  in  the 
urethra  behind  the  stricture  is  raised,  and  is  lowered  in  front  of  the 
stricture,  just  as  one  sees  the  pressure  in  a  common  garden-hose  affected 
by  constricting  the  tube  ever  so  slightly  with  the  fingers.  In  the 
urethra  the  effects  of  the  constriction  slowly  become  manifest,  and  the 
remote  symptoms  from  which  the  patient  suffers  eventually  appear  to 
be  due  to  the  constant  back  pressure  rather  than  to  the  mere  trifling 
inconvenience  of  emptying  the  bladder  slowly.  Behind  the  stricture 
the  dilatable  urethra  is  distended  and  may  be  permanently  sacculated 
even,  becoming  a  reservoir  for  small  amounts  of  urine  which  dribble 
away  after  the  act  of  micturition  has  been  checked.  In  this  dilated 
urethra  there  is  encouragement  for  a  process  of  chronic  inflammation, 
which  extends  often  to  the  prostatic  sinuses,  seminal  vesicles,  and  testes. 
Behind  the  prostate  the  bladder  is  called  upon  for  increased  work  in  order 
to  empty  itself  against  the  resistance  of  the  structure;  the  bladder  be- 
comes hypertrophied  and  may  become  sacculated ;  later  it  may  become 
thin-walled,  flabby,  distended,  and  incapable  of  proper  contraction; 
fre((uently  it  is  found  to  be  the  seatof  a  chronic  cystitis;  and,  finally,  the 
irritating  process  extends  to  the  ureters,  renal  pelves,  and  kidneys, 
until  the  whole  urinary  tract  is  involved  in  a  process  of  chronic  inflam- 
mation. One  sees  then  that  strictures  of  both  large  and  small  caliber 
are  not  lightly  to  be  regarded. 

The  treatment  of  organic  stricture  of  gonorrheal  origin  is  similar 
to  that  I  have  described  in  discussing  traumatic  stricture.  The  con- 
striction or  constrictions  must  be  located.  This  may  be  accomplished 
roughly  by  palpation  of  the  urethra  from  without  and  the  determination 
of  abnormal  thickenings  in  its  course.  For  the  more  accurate  ascertain- 
ing of  the  location  and  extent  of  strictures,  bougies  or  the  instrument  of 
Otis  suffice.  In  my  opinion  the  bougie  a  boule  is  most  useful.  Differ- 
ent sizes  of  this  instrument  are  used,  and  as  they  pass  into  and  beyond 
the  stricture  and  are  withdrawn,  they  are  made  to  determine  the  stric- 
ture's location  and  caliber.  They  will  fail  to  detect,  however,  a  stric- 
ture of  large  caliber  lying  behind  a  stricture  of  small  caliber.  To  deter- 
mine this  condition  the  urethrometer  of  Otis  is  invaluable.  Frequently 
the  surgeon  is  in  doubt  as  to  what  constitutes  a  stricture  of  large  caliber 
in  a  given  urethra.     He  may  determine  this  by  the  proportionate  scale 


STRICTUKE    OF   THE    URETHRA 


457 


of  mensurements  of  the  flaccid  penis,  which  I  have  already  described. 
Having  determined  the  site  and  extent  of  the  stricture,  the  surgeon 
may  cut  it  or  dilate  it  gradually.  In  general  terms  the  problem  re- 
solves itself  into  a  consideration  of  the  treatment  of  penile  strictures  or 
of  strictures  of  the  bulbomembranous  portion.  If  the  stricture  be  con- 
fined to  the  penile  }X)rtion,  and  if  an  instrument  can  easily  be  engaged  in 
it,  the  stricture  can  generally  be  stretched  to  a  proper  size  by  graduated 
steel  sounds.     This  operation  may  be  done  with  the  aid  of  cocain  anes- 


FT^ 


« 


Fig.  278. — Olivary  bougie 
(Fowler). 


Fig.  279.— Otis's  urethro- 
meter  (Fowler). 


A 


Fig.  280.— Dilating  urethro- 
tome of  Otis  (Fowler). 


thesia  (4  per  cent.),  the  size  of  the  sounds  being  increased  gradually 
by  three  or  four  sizes  at  each  sitting,  and  the  instruments  being  em- 
ployed once  every  five  or  ten  days.  By  this  means,  in  the  course  of  a 
month  or  two,  a  stricture  of  moderate  dimensions  maj^  be  cured;  but 
the  patient  should  be  instructed  to  have  his  urethra  searched  occasion- 
ally thereafter  in  order  to  anticipate  a  recontraction  of  the  stricture. 
If  the  penile  stricture  be  of  small  caliber,  and  if  it  does  not  jaeld  readih'', 
it  may  be  cut  with  the  Otis  urethrotome,  after  which  the  use  of  sounds 


458  GEMTO-UKINARY    ORGANS 

must  be  continued  for  several  weeks.  The  use  of  the  urethrotome  must 
be  limited  to  strictures  anterior  to  the  bulbomembranous  portion.  I 
do  not  believe  that  the  rapid  divulsion  of  strictures  in  the  penile  portion 
is  a  proper  operation  except  in  the  case  of  soft  strictures  of  large  caliber. 
Strictures  of  the  bulbomembranous  urethra  may  be  treated  with  sounds 
when  the  passage  of  sounds  is  possible.  In  a  large  proportion  of  cases 
this  treatment  is  sufficient.  In  the  case  of  complicated,  close,  and  un- 
yielding strictures,  however,  the  passage  of  sounds  is  impossible,  so 
that  under  these  circumstances  the  surgeon  must  resort  to  the  perineal 
section,  as  I  have  already  described  it.  Kapid  divulsion  of  close,  hard, 
deep  strictures  is  not  permissible,  because  rapid  divulsion  implies  vio- 
lent tearing  up  of  tissue,  which  may  cause  serious  hemorrhage,  and  leave 
the  lacerated  urethra  in  a  condition  which  admits  of  infection  and 
urinary  extravasation. 

So  much  for  the  treatment  of  stricture,  one  of  the  most  obstinate 
and  troublesome  of  the  sequelse  of  gonorrhea.  Patience  and  tact, 
almost  superhuman,  sometimes  are  needed  for  the  conduct  of  these  trj'- 
ing  cases. 

URETHRAL  FISTULA 

Urethral  fistula,  a  sinus  between  the  urethra  and  the  outside  world, 
is  a  condition  due  to  injurj^  or  to  the  breaking  outward  of  a  para- 
urethral abscess.  It  results  from  gonorrhea  generally.  These  fistulse 
may  discharge  a  part  or  the  whole  of  the  contents  of  the  bladder. 
Often  they  lie  behind  a  stricture,  which  complicates  the  situation. 
They  cannot  be  cured  by  mere  cureting  or  touching  with  caustic  or  the 
cautery,  as  used  to  be  attempted.  The  proper  treatmeni  is  to  divide 
them  freely  fromi  without — practical!}'  an  external  urethrotomy,  and 
then  to  curet  them  or  excise  them.  At  the  same  time  the  urethra  must 
be  cut  or  stretched  to  its  proper  size.  This  treatment  results  usually  in  a 
prompt  cure. 

URETHROSCOPY 

Urethroscopy  deserves  a  word  of  explanation,  for  it  is  the  means 
by  which  most  easily  the  interior  of  the  urethra  is  examined.  The 
principle  of  the  urethroscope  is  similar  to  that  of  the  female  cystoscope 
(described  in  Chapter  X) .  The  instrument  consists  of  a  hollow  steel  tube 
which  is  passed  into  the  urethra  and  is  used  in  connection  with  a  head- 
mirror,  which  throws  a  reflected  light  into  its  depths;  or  the  direct 
light  of  a  cold  lamp  near  the  distal  end  of  the  tube  itself  may  be  em- 
ployed. In  this  fashion  the  surgeon  inspects  the  lining  of  the  urethra. 
He  keeps  the  field  clean  with  swabs  of  absorbent  cotton  passed  through 
the  tube,  and  notes  such  abnormalities  as  congestion,  inflammation, 
patches  of  ulceration  and  cicatrices,  and  if  he  choses  he  makes  applica- 
tions directly  to  these  places.  In  this  way.  avoiding  copious  injection, 
he  is  able  to  treat  the  abnormal  processes  without  irritation  or  damage  to 
the  sound  portion  of  the  urethra.  The  most  useful  applications  are 
silver  nitrate  and  argyrol  in  varying  strengths.     The  surgeon  should  not 


HYPOSPADIAS   AND   EPISPADIAS 


459 


use  oil  or  vasclin  preparations  as  lubricants  to  the  urethroscope,  for 
the}-  smear  the  field  and  interfere  with  the  proper  action  of  applications. 
There  is  no  better  lubricant  than  glycerin.  It  may  seem  necessary  to 
use  cocain  in  some  cases,  but  this  should  be  avoided,  so  far  as  possible, 
lest  it  also  modify  the  action  of  the  silver  drug. 

HYPOSPADIAS  AND  EPISPADIAS 

Hijpospadias  is  an  abnormality  of  the  penis  due  to  defects  in  devel- 
opment. ^  The  urethra  opens  short  of  the  meatus.  Hypospadias  results 
from  a  failure  of  the  two  lateral  halves  of  the  penis  to  unite  on  the  lower 
median  surface.     Hypospadias  is  not  very  uncommon.     Epispadias  is 


#  / 


Fig.  281. — Beck's  operation  for  balanitic  hypospadias.     Line  of  incision. 

due  to  a  failure  of  union  of  the  upper  penile  surface,  and  is  rare.  I 
referred  to  it  in  discussing  exstrophy  of  the  bladder,  and  will  say  nothing 
further  of  it  here,  except  to  observe  that  hitherto  most  attempts  to  cure 
it  by  operation  have  been  discouraging.^ 

1  For  an  encouraging  case  see  Carl  Beck,  A  New  Method  of  Operation  for  Epis- 
padias, Med.  Record,  March  30,  1907. 


460 


GENITO-URINARY    ORGANS 


Hypospadias  is  of  varying  degrees,  and  frequently  has  been  relieved 
or  cured  by  operation.  It  may  appear  as  a  mere  enlargement  of  the 
meatus  downward,  or  the  urethra  may  end  and  discharge  above  the 
glans,  or  in  the  ]jcrincal  form  the  urethi'u  may  end  at  the  scrotum. 
The  symptoms  and  annoyance  of  the  condition  vary  with  the  location  of 


Fig.  282. — Beck's  operation  for  hypospadias. 

the  urethral  exit.  If  the  exit  be  in  the  glans,  there  results  discomfort 
merely  and  soiling  during  micturition,  but  there  is  no  interference  with 
procreation.  When  the  urethra  terminates  near  the  root  of  the  penis, 
however,  both  micturition  and  coitus  are  seriously  interfered  with,  and 
procreation  is  impossible. 


Fig.  283.  Fig.  284. 

Figs.  283  and  284. — Stinson's  operation  for  hypospadias.     Shows  incur\'ation, 

prepuce  retracted:     .4,  Shows  urinary  orifice  in  body  of  penis;  B,  shows  short  blind 
groove  in  body  back  of  glans  penis. 

The  treatment  of  balanitic  hypospadias  (that  form  in  which  the 
urethra  opens  beneath  the  crown  of  the  glans)  is  not  difficult  and  usually 
is  successful  through  the  medium  of  Beck's  operation.  This  consists  in 
dissecting  back  two  skin-flaps  along  the  urethra  for  about  two  inches, 
and  completely  dislocating  that  canal.     Then  a  false  canal  is  formed  in 


HYPOSPADIAS    AND    EPISPADIAS 


461 


the  glans  by  plunging  through  it  a  narrow-bladed  knife,  which  passes 
from  the  site  of  the  present  urethral  exit  out  through  the  site  of  the 
meatus  proper.  The  tip  of  the  dislocated  urethra  is  then  seized  with 
narrow  forceps,  is  dragged  through  the  new  canal,  and  is  stitched  to  the 
meatus.     The   skin-flaps   are  then   replaced.     Usually   this  operation 


Fig.  285. — Shows  urethral  orifice  (A) 
slit  up  to  No.  33  French,  separated  from 
its  surroundings,  and  edges  trimmed 
evenly.  B  shows  blind  groove  as  in 
Figs.  283  and  284,  but  with  prepuce  well 
retracted.  C,  C,  C  show  incisions  made 
for  the  formation  of  the  new  urethra. 


Fig.  286. — Shows  incisions  made 
and  flaps  of  mucous  membrane  and 
skin  being  dissected  up  for  new  urethra 
in  the  glans  and  body  of  the  penis.  C, 
C  show  raw  surface  of  the  glans  after 
lifting  flaps. 


results  in  a  complete  cure,  but  narrowing  at  the  proper  site  of  the  fossa 
navicularis  may  occur  after  the  operation  and  necessitate  subsequent 
sounding.  The  treatment  of  penile  or  perineal  hypospadias  is  by  no 
means  so  easy,  and  is  certainly  difficult  of  demonstration,  I  have 
employed  with  satisfaction  the  method  described  by  Stinson  ^     This 


Fig.  287.— The  same  as  Fig.  288  ex- 
cept that  dotted  line  {D)  show  flaps 
brought  edge  to  edge. 


Fig.  288.— Shows  the  edges  of  the 
flaps  taken  from  the  glans  and  body, 
sutured  to  each  other  to  form  new 
urethra. 


writer  lays  stress  on  the  importance  of  rectifying  the  clown  curve  of  the 
penis,  which  is  found  at  the  site  of  the  urethral  orifice.  This  incurvation 
is  remedied  by  dissecting  the  urethra  from  its  attachments  at  that  point 
and  dividing  all  constricting  bands  by  transverse  incisions,  so  as  thor- 

*  J.  Coplin  Stinson,  Improved  Operation  for  Hypospadias  Involving  the  Glans 
and  Penile  Portion  of  the  Urethra,  Jour.  Amer.  Med.  Assoc,  December  2,  1905. 


462 


GENITO-UIUNARY   ORGANS 


oughly  to  straighten  the  organ,  taking  pains  at  the  same  time  not  to 
damage  the  corpora  cavernosa.  The  further  operation  is  briefly  as  fol- 
lows: (1)  Drain  the  bladder  by  perineal  section  and  maintain  the  drain- 


Fig.  289.— Shows  same  as  Fig.  288,  A, 
and  anastomosis  made  between  the  new 
and  old  urethral  orifices.  B  shows  the 
end  of  new  urethra  in  glans  penis.  D 
shows  raw  surfaces  of  glans  and  body- 
whence  the  flaps  have  been  taken. 


Fig.  290. — Shows  the  newly  placed 
prepuce,  cut  down  the  median  line  and 
its  layers  of  mucous  membrane  (E)  and 
skin  {F)  being  dissected  from  each 
other  ready  to  be  used  to  cover  com- 
pletely the  raw  surfaces  of  the  glans  and 
body  of  the  penis,  and  also  to  bury  the 
stitches  uniting  the  edges  of  new  urethra 
and  forming  anastomoses  between  the 
new  and  old  urethras. 


age  during  the  patient's  convalescence  from  the  plastic  operation  on  the 
penis.     (2)  Enlarge  the  urethral  orifice  with  a  No.  33  French  sound; 


Fig.  291. — Shows  layers  of  mucous  membrane  (E)  and  skin  (F)  separated  from 
each  other  (shown  on  the  right  side  of  figure)  trimmed,  put  in  place  in  their  respective 
positions,  and  sutured  to  the  vertical  cut  edges  of  the  glans  and  body,  whence  the 
layers  were  taken  to  form  new  urethra  {E  and  F)  (shown  on  left  side  of  figure). 
The  raw  surface  on  left  side  is  completely  covered  by  the  mucous  and  skin  layers,  which 
are  also  sutured  transversely  to  each  other. 

form  a  new  canal  by  turning  over  longitudinal  flaps  of  skin  and  mucous 
membrane,  and  sew  these  flaps  together  longitudinally,  skin  side  in,  and 
to  the  old  urethra  at  their  proximal  end.     This  establishes  a  new  urethral 


HYPOSPADIAS    AND    EPISPADIAS 


463 


canal  The  hood,  or  prepuce,  is  employed  to  cover  over  the  raw  surfaces. 
In  order  to  bring  this  loose  skin  of  the  hood  into  position  for  this  pun30se, 
it  is  dissected  back  for  a  short  distance  from  the  corona;  a  transverse 
split  is  then  cut  in  it  on  the  dorsum,  and  through  this  slit  the  glans  penis 
i.  passed.  As  a  result  of  this  maneuver  practically  the  whole  of  the 
prepuce  lies  flapping  beneath  the  glans  and  is  ready  to  be  utilized  tor 


Fio-.  292. — Shows  separation  of  pre- 
putial''hood  (F),  which  consists  of  two 
layers,  skin  (E)  and  mucous  membrane 
{H). 


Fig.  293.— Shows  the  preputial 
hood  brought  down  underneath  the 
glans  by  carrying  the  glans  through  the 
transverse  opening  in  the  prepuce.  E 
shows  layer  of  mucous  membrane.  F 
shows  layer  of  skin. 


covering  in  the  raw  surface  over  the  urethra.  The  loose  prepuce  is  now 
cut  down  in  its  median  line,  if  necessary,  and  its  layers  of  mucous  mem- 
brane and  skin  are  dissected  from  each  other,  are  trimmed  as  required 
and  are  adjusted  and  sutured  to  the  vertical  cut  edges  of  the  glans  and 
to  the  body  of  the  penis,  so  as  accurately  to  cover  m  the  raw  surfaces. 
If  the  original  deformity  presents  as  a  perineal  fistula,  the  raw  surfaces 


Ficr  294— Shows  the  layers  of  mucous  membrane  and  skin  as  in  Fig  284  F, 
sutured  in  tlieir  new  positions  to  the  vertical  edges,  transversely  to  each  other  the 

surfaces  on  the  under  aspect  of  the  glans  and  body  of  the  penis.      V\  mie  tne  cux  ao 
the  median  line  was  made  in  this  case,  usually  this  should  not  be  done. 

left  by  the  infolding  of  skin  in  the  operation  may  be  covered  by  a  loose 
flap  taken  from  the  scrotum.  After  completion  of  the  operation  the 
whole  wound  must  be  dressed  carefully,  and  the  part  suspended  m  proper 
bandages,  and  the  patient  must  be  put  to  bed  for  ten  days  at  eas  ^ 
During  this  time  there  will  have  been  no  soihng  by  urme  as  the  uime  is 
drained  away  through  the  perineum.     At  the  end  of  ten  days  a  catheter 


464 


GENITO-URINARY    ORGAN'S 


may  be  passed  throiifih  the  newly  formed  urethra  into  the  bladder,  and 
the  perineal  wound  ma}'  be  allowed  to  close.     This  is  one  of  numerous 


Fig.  295.  Fig.  296.  Fig.  297. 

Figs.  295,  296,  and  297. — Showing  the  correction  of  the  convexity  and  the  trans- 
verse constrictions  on  the  upper  surface  of  the  body  by  making  al^out  an  inch  long 
vertical  incision  in  the  median  line  backward  from  the  transverse  incision  made  in 
separating  hood  and  dissecting  up  and  bringing  forward  and  suturing  it  in  tlie  -same 
line  continuous  with  the  transverse  incision.  This  shortens  the  anteroposterior 
measurements  and  increases  the  transverse  measurement. 

operations  devised  for  the  correction  of  hypospadias.     I  have  found  it 
satisfactory  and  recommend  it. 


The  Testicles 

Diseases  of  the  testicles,  of  the  vasa  deferentia,  and  of  the  seminal 
vesicles  are  closely  associated,  and  a  clear  comprehension  of  the  anatomy 
of  these  parts  is  essential  to  the  surgeon.  In  fetal  life  the  testicles  lie 
within  the  abdominal  cavity,  but  at  varying  times,  usually  in  the  seventh 
or  eighth  months  of  intra-uterine  life,  they  descend  through  the  inguinal 
canal  and  are  found  in  the  scrotum  at  birth.  In  a  considerable  number 
of  male  infants,  however,  one  or  both  of  the  testicles  are  found  un- 
descended at  the  time  of  birth,  an  abnormality  which  may  well  be  a 
cause  of  serious  anxiety  to  the  child's  parents  when  they  regard  his 
future. 

UNDESCENDED   TESTICLE  i 

Lack  of  descent  of  both  testicles  may  threaten  sterility,  for  after 
puberty  undescended  testicles  seldom  functionate.  Furthermore,  in 
any  case  of  undescended  testicle,  whether  the  deformity  be  double  or 
single,  the  retained  organ  is  peculiarly  subject  to  malignant  changes, 
so  that  sarcoma  of  the  undescended  testicle  has  come  properly  to  be 
dreaded.  I  have  seen  two  grievous  examples  of  this  calamity.  For 
this  reason,  when  I  am  consulted  by  a  man  himself  the  victim  of  un- 
descended testicle,  I  advise  removal  of  the  organ,  for  it  is  functionless  in 
an  adult,  and  liable  to  become  the  seat  of  sarcoma.  In  boys  below  the 
age  of  puberty,  however,  it  is  rea.sonable  to  attempt  a  proper  placing  of 
the  dislocated  organ.  In  a  great  majority  of  cases  it  is  found  outside  of 
or  within  the  inguinal  canal,  rarely  within  the  abdominal  cavity.  In 
any  case  it  may  often  be  brought  down  into  proper  position.  For  cen- 
turies surgeons  have  endeavored  to  correct  the  deformity  of  undescended 

^  Walter  B.  Odiorne  and  Channing  C.  Simmons,  Ann.  Surg.,  1904,  vol.  xl,  p.  962, 
present  an  admirable  resume  of  this  subject. 


UNDESCENDED   TESTICLE 


465 


testicle,  but  with  varying  success.  Certain  procedures,  however,  have 
come  to  be  regarded  as  serviceable,  and  in  some  half-dozen  instances 
I  have  been  satisfied  to  follow  the  technic  of  Bevan,  who  has  operated 
satisfactorily  on  a  large  series  of  cases. ^  Bevan  points  out  that,  for 
clinical  purposes,  we  may  divide  the  condition  of  undescended  testicle 
into  four  groups : 

1.  Simple  failure  of  the  vaginal  process  to  close,  giving  us  the  picture 
of  a  congenital  inguinal  hernia. 

2.  Incomplete  closure,  complicated  with  such  conditions  as  hydro- 
cele of  the  cord. 

3.  Undescended  testis,  which  presents  four  types:  (a)  in  the  ab- 
domen in  about  its  original  position:  (b)  at  the  internal  ring;  (c)  in  the 
canal ;  (c/)  external  to  the  external  ring. 


Fig.  298. — Bevan's  operation.  Inci- 
sion through  skin  (3),  superficial  fascia 
(4),  and  external  oblique  (1);  2,  cremas- 
teric fascia  (Bevan  in  Keen's  Surgery). 


Fig.  299. — Bevan's  operation:  1, 
Point  where  vaginal  process  of  perito- 
neum is  cut;  2,  vaginal  process  open,  ex- 
posing the  testicle;  3,  testicle  (Bevan  in 
Keen's  Surgery). 


4.  Misplaced  testicle:  (a)  in  the  perineum;  (b)  on  the  thigh  below 
Poupart's  ligament. 

He  further  points  out  that  statistics  show  the  deformity  to  occur  at 
least  once  in  500  male  children. 

Bevan  asserts  also  that  an  operation  to  bring  the  organ  down  into 
the  scrotum  practically  always  is  possible,  and  that  there  are  few  cases 
in  which  an  operation  is  not  indicated.  As  I  have  stated,  I  limit  my 
operations  for  proper  placing  of  the  organ  to  the  case  of  boys,  and  believe 
strongly  that  the  undescended  testicle  in  a  man  should  be  excised. 

Bevan's  operation  for  undescended  testicle  is  performed  as  follows — 
and  the  sketches  adapted  from  Bevan's  article  will  illustrate  the  theme : 

'  Arthur  Dean  Bevan,  The  Surgical  Treatment  of  Undescended  Testicle,  Jour. 
Amer.  Med.  Assoc,  September  19,  1903. 

30 


466 


GENITO-UKIXARY   ORGANS 


Cut  down  upon  the  groin  as  though  for  the  operation  of  inguinal  hernia; 
open  the  inguinal  canal,  and  lay  bare  the  cord,  testicle,  and  vaginal 


Fig.  300. — Bevan's  operation — step  3.     Showing  vaginal  process  cut  across  above 

testis. 


process  (the  large  peritoneal  sac  containing  the  testes,  and  continuous 
with  the. peritoneal  cavity).     Open  the  sac,  expose  the  testicle,  and  re- 


Fig.  301. — Bevan's  operation:  1, 
Upper  end  of  vaginal  process  of  peri- 
toneum ligated;  2,  purse-string  suture 
closing  lower  end  of  vaginal  process  and 
forming  a  tunica  vaginalis  for  the  testicle 
(Bevan  in  Keen's  Surgery). 


Pig.  302. — Bevan's  operation.  Cord 
lengthened  and  testicle  freed  and  ready 
for  replacement;  2,  the  spermatic  vessels; 
3,  the  vas  deferens  (Bevan  in  Keen's  Sur- 
gery). 


duce  any  hernia  which  may  be  present.     Then  cut  across  the  vaginal 
process  above  the  testicle  and  secure  the  proximal  stump  as  in  the  case 


UNDESCENDED   TESTICLE 


467 


of  a  hernia.  Sew  up  the  distal  portion  of  the  vaginal  process  about  the 
testicle,  and  so  furnish  that  organ  with  a  tunica  vaginalis.  It  now 
remains  to  bring  the  testicle  into  the  scrotum,  and  this  is  done  by  a 
process  of  traction  on  the  cord  and  the  division  of  retaining  bands. 
To  this  end  the  cord  is  stripped  up,  leaving  nothing  but  the  vessels  and 
the  vas,  which  in  turn  must  be  separated  carefully  from  the  parietal 
peritoneum.  By  this  means,  in  nearly  all  cases,  the  cord  may  be  elon- 
gated satisfactorily.  A  pocket  in  the  scrotum  is  then  readily  made  with 
blunt-pointed  scissors  and  the  fingers;  the  testicle  is  dropped  into  the 
pocket  and  is  held  in  place  by  a  catgut  purse-string  ligature,  passed 
subcutaneously  about  the  neck  of  the  scrotum.  The  surgeon  then 
restores  the  wounded  canal,  sews  up  the  inguinal  hernia,  and  dresses  the 


Fig.  303. — Bevan'6  operation.  Mak- 
ing pocket  in  right  side  of  scrotum  for 
reception  of  the  testicle  (Bevan  in  Keen's 
Surgery). 


Fig.  304. — Bevan's  operation.  Su- 
tures closing  the  wound  (Bevan  in  Keen's 
Surgery). 


wound  with  a  firmly  applied  spica  bandage.  The  patient  should  be  kept 
in  bed  for  two  weeks  at  least  after  the  operation. 

In  rare  cases  one  finds  that  the  cord  cannot  properly  be  drawn  down 
and  that  this  is  due  to  short  spermatic  vessels,  and  not  to  a  short  vas. 
Bevan  has  found,  and  his  experience  coincides  with  my  own,  that  the 
spermatic  vessels  may  be  cut  away  in  such  cases,  without  danger, 
leaving  the  vas  and  its  vessels  only.  When  this  is  done,  a  sufficiently 
long  cord  is  obtained. 

Absence  of  the  testicle  is  a  condition  allied  etiologically  to  unde- 
scended testicle.  In  two  cases  of  apparent  double  undescended  testicle 
I  have  been  unable  at  operation  to  find  more  than  one  testicle  in  each 
patient.  I  did  find,  however,  on  the  opposite  side,  an  attenuated  cord, 
terminating  in  a  pinch  of  tissue  which  doubtless  represented  a  rudi- 
mentary testicle.     In  such  a  case  the  cord  with  its  terminal,  useless 


468  GENITO-URINARY   ORGANS 

tissue  should  carefully  be  dissected  away,  while  at  the  same  time  the 
undescended  organ  on  the  other  side  should  be  brought  down  into  the 
scrotum. 

WOUNDS  AND   CONTUSIONS   OF   THE  TESTICLE 

Wounds  and  contusions  of  the  testicle  are  discussed  by  most  writers 
on  the  surgery  of  this  organ,  but  in  truth  such  wounds  and  contusions 
differ  in  no  essential  from  wounds  and  contusions  of  any  of  the  soft  parts, 
and  the  extent  of  treatment  depends  upon  the  extent  of  the  lesion.  The 
damaged  structures  should  be  cleaned  up  thoroughly  and  supported 
upon  a  pillow,  between  the  legs,  or  on  a  towel  shng.  Mere  contusions 
should  be  treated  on  the  lines  I  have  laid  down  for  the  treatment  of 
epididymitis,  because  an  acute  and  painful  exudate  with  swelling  is  wont 
to  occur.  If  the  scrotum  is  found  torn  open  with  the  testicle  exposed 
or  lacerated,  the  injured  parts  should  be  repaired  so  far  as  possible,  and 
the  testicle  should  be  replaced  in  its  normal  coverings.  Do  not  suture 
the  proper  tunic  of  the  testicle  (tunica  albuginea).  Take  pains  to  drain 
carefully  the  vaginal  sac,  lest  a  troublesome  hematoma  form  within  it. 
The  soft  parts  should  be  sutured  with  interrupted  silkworm-gut  stitches. 
Castration  rarely  is  required  in  these  cases,  but  w^hen  necessary,  on  ac- 
count of  sloughing,  may  be  performed  as  a  secondary  operation. 

Hematocele  of  the  tunica  vaginalis  is  a  condition  which  I  referred 
to  above  as  a  hematoma.  It  arises  from  an  accidental  injury  or  may 
occur  through  hemorrhage  from  a  vein,  wounded  in  the  little  operation 
of  tapping  a  hydrocele.  Hematocele  of  the  cord  is  a  condition  analogous 
to  hematocele  of  the  tunica  vaginalis,  and  occurs  beneath  the  tissue 
which  surrounds  the  cord.  Obviously,  having  no  marked  barriers 
below  or  above,  it  extends  up  and  down  the  cord  and  foi'ms  a  sausage- 
shaped  swelling.  Both  forms  of  hematocele  may  become  absorbed 
under  rest  and  cold  applications  if  the  damage  is  recent  and  the  accumu- 
lation of  blood  is  small.  In  the  case  of  long-standing  and  large  collec- 
tions of  blood  the  surgeon  may  have  to  resort  to  incision  and  drainage. 

INFLAMMATION   OF   THE  TESTICLE 

Inflammation  of  the  testicle  proper  (orchitis)  is  an  infrequent  con- 
dition, and  when  present,  is  usually  associated  with  an  epididymitis. 
Orchitis  may  be  the  result  of  an  injur}",  or  may  be  the  sequel  of  a  gonor- 
rhea. The  treatment  which  I  have  described  for  epididymitis  is  applic- 
able to  cases  of  orchitis.  You  must  distinguish  carefully  the  syphilitic 
and  the  tuberculous  forms  of  orchitis  from  the  ordinary  traumatic 
and  infectious  varieties,  and  from  syphilitic  e])ididymitis. 

Syphilitic  epididymitis  is  marked  by  its  slow  progress,  by  its  devel- 
opment first  in  the  globus  major,  and  by  the  relative  absence  of  pain. 
Obviously,  the  treatment  is  by  a  supporting  bandage  and  by  antisyphilitic 
remedies. 

Syphilitic  orchitis  proper  (sarcocele)  occurs  as  an  infiltration  of 
the  testicle.     One  finds  it  usually  between  the  second  and  fourth  years 


INFLAMMATION    OF   THE   TESTICLE  469 

of  the  syphilis,  in  which  respect  it  contrasts  with  syphihtic  epididymitis, 
which  develops  conimonl}-  somewhere  between  the  second  and  seventh 
months.  In  sarcocele  there  is  a  slow  gunmiatous  infiltration,  with 
nodules,  either  single  or  multiple,  and  with  little  tendency  to  suppura- 
tion. Such  pain  as  exists  is  inconsiderable.  The  process,  if  untreated, 
advances  to  destruction  of  the  organ  and  its  envelops,  to  fistula  for- 
mation, and  to  involvement  of  the  scrotum.  In  making  his  diagnosis  of 
these  syphilitic  lesions  the  surgeon  arrives  at  a  history  of  syphilis  and 
its  sundry  manifestations,  and  differentiates  the  condition  from  gonor- 
rheal complications,  which  are  acute  and  painful;  from  tuberculosis, 
which  syphilis  most  closely  resembles;  and  from  malignant  disease,  which 
is  slow,  painful,  and  is  a  new-growth,  rather  than  a  destruction  of  tissue. 
The  treatment  of  the  syphilitic  orchitis  consists  always  in  the  adminis- 
tration of  mercury  and  potassium  iodicl,  and  in  the  operative  removal 
of  detritus  and  all  disorganized  tissue. 

Tuberculosis  of  the  testicle  and  epididymis  is  a  frequent  affec- 
tion. It  is  grave.  Its  treatment  is  interesting,  and  has  been  the  sub- 
ject of  sharp  debate.  The  disease  is  rarely  primary,  but  when  it  is  so, 
the  epididymis  is  the  first  portion  to  be  affected,  and  thence  the  process 
extends  to  the  testicle  proper.  In  fact,  as  Fowler  says,  the  epididymis 
is  the  starting-pomt  of  urogenital  tuberculosis  in  more  than  half  the 
cases.  It  is  needless  to  discuss  the  etiology  of  tuberculosis  within  the 
scrotum  further  than  to  observe  that  it  occure  at  all  ages,  though  it 
is  most  frequent  in  young  manhood.  Tuberculosis  within  the  scrotum, 
when  present  in  young  men,  is  primary  often.  When  seen  in  the  very 
young  and  in  elderly  persons,  it  is  most  often  part  of  a  general  tuber- 
culosis. 

Tuberculosis  of  the  testicle  is  seen  almost  always  in  the  caseous  stage, 
and  the  caseous  deposits  are  multiple.  They  break  dow^n  ^nd  form 
numerous  pockets  or  abscess  cavities.  The  vas  is  involved  for  varying 
distances. 

The  symptoms  are  insidious,  for  the  disease  develops  slowly,  as  a  rule, 
though  in  the  case  of  a  concurrent  gonorrheal  epididymitis  a  mixed  in- 
fection results  and  the  progress  of  the  disease  is  rapid.  Ordinarily,  tu- 
berculosis of  the  testicle  gives  little  pain  or  evidence  of  tenderness  at  first. 
Gradually  the  organ  breaks  down,  but  the  patient's  first  consciousness 
of  trouble  may  arise  from  observing  a  complicating  hydrocele  or  a  slight 
urethral  discharge.  Generally,  the  disease  begins  in  the  globus  major 
and  extends  in  both  directions.  When  a  swelling  of  the  testicle  proper 
can  be  felt,  one  discovers  it  to  be  hard  and  nodular.  The  nodules  in- 
crease in  size  and  number,  they  break  down,  form  abscesses  with  as- 
sociated pain  and  tenderness,  involve  the  skin,  and  produce  one  or  more 
sinuses.  Often,  when  the  surgeon  is  consulted,  he  finds  a  dischargmg 
fistula  leading  to  the  broken-down  caseous  testicle.  In  making  the 
diagnosis,  when  the  case  is  seen  fairly  early,  one  must  differentiate  it 
from  syphilitic  testicle.  The  tuberculous  testicle  feels  nodular;  the 
syphilitic  testicle  feels  uniform  and  smooth.  Sometimes  both  testicles 
are  involved  in  tuberculosis.     Per  contra;  double  sarcocele   (syphilis) 


470  GENITO-URINARY    ORGANS 

is  extremely  rare.  When  a  tuberculous  testicle  is  discovered,  the  surgeon 
should  examine  carefully  the  prostate,  vesicles,  bladder,  and  kidneys  to 
ascertain  an  extension  of  the  process.  Frequently  he  will  find  tuber- 
culous disease  of  the  prostate  and  vesicles;  less  often  of  the  bladder,  and 
more  rarely  of  the  kidneys. 

I  said  that  the  question  of  treatment  had  been  hotly  debated.  The 
opposing  views  taken  in  the  discussion  were,  whether  or  not  castration 
invariably  should  be  performed.  Opinions  of  surgeons  are  now  fairly 
unanimous.  Castration  is  the  rule — castration  unless  an  extensive 
general  tuberculosis  coexists.  Tuberculous  disease  of  the  prostate  and 
vesicles  does  not  contraindicate  castration.  When  castration  is  done 
for  tuberculous  orchitis,  the  surgeon  should  not  rest  content  with  the 
operation,  but  should  prescribe  invariably  a  long  course  of  antitubercu- 
lous  treatment — an  out-of-doors  life;  and  the  ])atient  should  continue 
this  until  his  normal  weight  is  reestablished  and  his  general  condition 
is  satisfactory  to  his  adviser. 

The  operation  of  removal  of  the  testicle  (orchidectomy  or  castration) 
should  be  done  through  a  long  incision  beginning  over  the  inguinal 
canal  and  running  down  on  to  the  skin  af  the  scrotum.  The  surgeon 
should  tie  off  the  vas  high  early  in  the  operation,  and  should  perform 
his  dissection  from  above  downward,  removing  thoroughly  with  knife 
and  scissors  all  involved  tissue.  He  should  not  hesitate  to  sacrifice 
large  areas  of  skin.  This  tying  off  of  the  vas  high  at  the  beginning  of 
the  operation  is  important,  for,  as  George  Walker  has  pointed  out, 
failure  to  cut  off  the  vas  before  manipulating  the  disease  itself  may  re- 
sult in  the  forcing  of  disease  organisms  up  into  the  abdominal  por- 
tion of  the  vas,  with  a  consequent  prompt  development  of  tuberculous 
vesiculitis.  The  dissection  wound  in  the  scrotum  should  be  painted  with 
tincture  of  iodin,  sewed  up  with  interrupted  stitches  of  silkworm  or 
silver,  and  drained  from  the  most  dependent  point.  If  the  work  has 
been  done  thoroughly,  convalescence  should  be  short,  and  the  patient 
should  be  up  and  about  at  the  end  of  two  weeks. 

HYDROCELE 

Hydrocele  means  properly  an  accumulation  of  watery  fluid  within  a 
sac,  and  the  term  hydrocele  is  applied  to  various  structures  and  regions. 
Commonly,  however,  we  mean  by  hydrocele  an  accumulation  of  serum 
within  the  tunica  vaginalis.  There  is  also  hydrocele  of  the  cord,  similar 
to  that  hematocele  of  the  cord  of  which  I  have  spoken.  There  is  con- 
genital hydrocele,  in  which  case  the  vaginal  process  has  remained  opened, 
so  that  the  tunica  vaginalis  communicates  with  the  peritoneal  cavity. 
This  condition  commonly  is  associated  with  congenital  hernia.  Hydro- 
cele of  the  tunica  vaginalis  may  be  either  acute  or  chronic.  The  acute 
form  is  associated  usually  with  inflammation  of  the  testicle  and  epididy- 
mis, whether  resulting  from  injury  or  disease.  Such  acute  complicating 
hydroceles  require  little  treatment  beyond  the  care  of  the  underh'ing 
lesion.      Sometimes,  if  the  accumulated  fluid  persists  for  long,  it  may 


HYDROCELE  471 

be  drawn  off  through  a  trocar  (aspiration  of  the  distended  scrotum  with 
a  hollow  needle). 

Chronic  hydrocele  of  the  tunica  vaginalis  is  the  condition  com- 
monly meant  by  the  term  "hydrocele."  The  cause  of  chronic  hydro- 
cele is  not  entirely  apparent,  though  such  recent  observers  as  Kocher, 
Langerhans,  and  Konig  have  found  evidence  of  inflammation  both  in 
the  accumulated  fluid  and  in  the  wall  of  the  sac.  Traumatism  may  be 
a  cause  of  hytlrocele,  and  small  retention  cysts  (spermatocele),  either 
in  the  testis  or  epididymis,  may  give  rise  in  turn  to  hydrocele.  What- 
ever the  cause,  chronic  hydrocele  develops  slowly,  often  with  thickening 
of  the  tunica,  and  an  accumulation  of  fluid  within  its  cavity.  This 
form  of  serous  accumulation  differs  markedly  in  its  origin  from  effusion 


Fig.  305. — Use  of  the  hydroscope  for  inspecting  a  hjairocele. 

into  the  pleural  cavit}' — an  effusion  commonly  tuberculous.  Long- 
standing hydroceles  grow  to  a  great  size,  and  the  sac  often  becomes  one- 
fourth  inch  thick  or  more.  The  tumor  ma}^  be  as  large  as  a  child's  head 
even.     It  is  unilateral  generally. 

The  symptoms  of  hydrocele  are  annoying  rather  than  painful. 
Their  onset  is  insidious.  There  is  some  sense  of  dragging  and  weight, 
but  generally  the  patient  complains  of  the  size  onl}"  of  the  tumor. 
The  sac  is  rather  ovoid  in  shape,  and  the  swelling  extends  from  the  tip 
of  the  scrotum  up  toward  the  inguinal  ring.  You  must  differentiate  it 
from  inguinal  hernia.  Both  fluctuate,  but  hydrocele  is  rather  the  more 
tense.  Hydrocele  does  not  vary  in  size  with  the  position  of  the  patient 
nor  is  there  to  be  felt  an  impulse  on  coughmg.     The  classic  demonstra- 


472  GENITO-URINARY    ORGANS 

tion  of  hydrocele  consists  in  looking  through  it  at  a  strong  light  and  using 
as  an  instrument  of  inspection  a  straight  hollow  tube  (hydroscope), 
which  is  held  firmly  against  the  distended  scrotum  with  the  light  on  the 
opposite  side  of  the  tumor.  \\'hen  you  look  through  the  tube,  you  will 
see  a  translucent  zone  at  the  end  of  the  hydroscope  if  the  sac  is  distended 
with  serum  only.  In  the  case  of  a  hernia,  such  translucency  is  not  ap- 
parent. There  is  one  source  of  error  in  this  method  of  determining  a 
hydrocele :  blood  in  the  hydrocele  fluid  or  an  extremely  thick  wall  may 
obscure  the  light,  and  one  must  make  allowance  for  these  conditions. 
Of  course,  other  tumors  of  the  scrotum,  such  as  neoplasms,  will  obscure 
the  light  also.  If  the  case  remains  in  doubt  after  those  tests,  there  is  no 
harm  in  aspirating  the  sac  and  drawing  off  the  Ikiid  for  examination. 


1 


y^ 


Fig.  306. — Tapping  a  hydrocele. 

The  outlook  is  good  in  cases  of  simple  hydrocele,  though  extreme 
thickening  of  the  tunic  (peri-orchitis  prolifera)  may  produce  pressure 
atrophy  of  the  testis. 

The  best  treatment  of  hydrocele  is  operative.  PalHative  treatment 
is  by  the  use  of  a  suspensory  bandage  or  by  repeated  tappings.  Some 
persons,  especially  debilitated  old  men,  prefer  the  tapping,  and  this 
little  operation  is  not  very  painful.  It  may  be  rendered  painless  by 
cocainizing  the  area  to  be  aspirated.  To  tap  the  scrotum,  seize  the  mass 
firmly  behind  with  one  hand,  and  thus  make  tense  the  sac.  Plunge  the 
trocar  into  the  sac  in  front  about  three-quarters  of  the  way  down. 
Guard  the  trocar  against  sinking  in  too  deeply  and  wounding  the  testicle 
by  holding  the  forefinger  of  the  active  hand  firmly  against  the  cannula 
about  one  inch  from  the  tip.     Select  a  spot  free  from  veins,  lest  a  blood- 


HYDROCELE  473 

vessel  be  wounded  and  bleed  into  the  sac,  thus  setting  up  a  hematocele. 
If  tapping  only  be  employed,  it  must  be  repeated  from  time  to  time  as 
the  sac  refills. 

The  radical  cure  of  hydrocele  may  follow  tapping  if  proper  injections 
be  made  into  the  sac.  George  W.  Gay  writes:  "  For  a  radical  cure  of 
hydrocele  the  best  procedure  I  know  is  the  following:  draw  off  the 
serum,  and  then  inject  2  to  4  drams  of  a  mixture  of  equal  parts  of  car- 
bolic acid  (95  per  cent.),  glycerin,  and  alcohol,  and  allow  it  to  remain. 
The  pain  is  not  severe.  The  patient  goes  about  his  business,  and  the 
cure  is  reasonably  certain."  An  adhesive  inflammation  results,  which 
often  cures  the  hydrocele  after  one  operation.  I  prefer  to  keep  the  pa- 
tient quiet  for  at  least  twenty-four  hours  after  the  operation,  with  the 
scrotum  well  supported  and  padded  with  cotton.  Occasionally  I  have 
seen  this  method  fail,  the  failure  being  due  mainly  to  excessive  thicken- 
ing of  the  wall  of  the  sac.  Under  such  circumstances, — indeed,  under 
nearly  all  circumstances,- — if  the  surgeon  so  choose,  one  may  revert  to 
some  one  of  the  radical  operations  for  hydrocele.  It  is  needless  here  to 
discuss  these  various  procedures.  Volkmann's  operation  and  Longuet's 
operation  are  favorites  with  many  surgeons.  For  myself  I  have  been 
abundantly  satisfied  with  the  so-called  "  high  operation."  This  con- 
sists in  cutting  down  upon  the  spermatic  cord  above  Poupart's  ligament, 
as  in  the  operation  for  inguinal  hernia;  loosening  the  cord  from  its  bed; 
enlarging  the  incision  down  to  the  root  of  the  scrotum ;  and  then  everting 
the  hydrocele  sac,  with  the  testicle,  through  the  w^ouncl,  and  separating 
the  tunica  from  its  envelops  by  blunt  dissection,  with  the  occasional  cut- 
ting of  fibrous  adhesions  and  enlarged  vessels.  This  brings  out  upon  the 
abdominal  wall  the  loosely  hanging  hydrocele  mass  attached  to  the  cord 
only.  The  next  step  consists  in  opening  the  sac  and  cutting  away  care- 
fully the  whole  of  the  parietal  layer,  leaving  the  uncovered  testicle  hang' 
ing  at  the  end  of  the  cord.  The  testicle  is  then  slipped  back  into  the 
scrotum  and  the  wound  is  sewed  up.  Frequently  there  is  a  good  deal 
of  hemorrhagic  oozing  from  torn  vessels  on  the  interior  of  the  scrotal 
wall.  For  this  reason  it  is  safe  practice  to  drain  with  tubing  the  scrotum 
through  a  stab  wound  at  its  lowest  point.  Twenty-four  hours  of  drainage 
should  suffice.  I  advocate  strongly  this  high  operation  for  the  following 
reasons:  it  cures  hydrocele;  it  removes  the  external  wound  from  the 
scrotal  tissues,  which  are  difficult  to  cleanse  and  render  aseptic;  the 
wound  in  the  groin  is  far  less  irritating  to  the  patient  during  his  conva- 
lescence than  is  a  wound  in  the  scrotum,  and  it  is  more  easily  dressed ;  the 
trimming  off  of  the  tunic  or  the  handling  of  the  testicle  and  frequently 
associated  enlarged  veins  is  simplified  by  this  method. 

After  the  operation  the  patient  should  be  kept  in  bed  for  a  week  or 
ten  days  and  then  be  allowed  to  go  about  with  a  suspensory  bandage 
for  a  month,  when  all  danger  of  further  irritation  or  recurrence  should 
have  disappeared. 

As  for  congenital  or  communicating  hydrocele  of  the  new-born 
the  treatment  is  simple.  Usually  a  compressing  truss  or  pad  will  bring 
about  obliteration  of  the  open  vaginal  process.     Sometimes  aspiration 


474  GENITO-UKIN'ARY    ORGANS 

of  the  sac  may  be  necessary.  Rarely,  a  cutting  operation  and  tying  off 
of  the  sac  must  be  resorted  to,  but  this  need  not  be  done  within  the  first 
year  after  birth.  Under  no  circumstances  should  one  attempt  to  cure 
communicating  hydrocele  by  strong  irritant  injections. 

Spermatocele,  a  rare  form  of  cystic  tumor  of  the  testis,  simulates 
hj-drocele  and  occurs  after  puberty.  The  contained  fluid  is  loaded  with 
spermatozoa.  To  cure  it,  try  tapj^ing  first.  If  that  does  not  succeed, 
incise,  pack,  and  drain  the  cyst. 

VARICOCELE 

Varicocele  of  the  spermatic  cord  is  regarded  ))y  the  ordinar}'  citizen 
as  a  mysterious  and  baneful  affection.  Medical  students  even  have  been 
puzzled  by  it.  It  is  merely  a  varicose  condition  of  the  veins  in  the  cord 
and  scrotum,  and,  as  in  the  case  of  varicosities  elsewhere,  it  may  be 
cured  by  removing  the  veins.  The  left  side  of  the  scrotum  is  more  com- 
monly afTected  than  the  right.  About  87  per  cent,  of  the  cases  are  on 
the  left  side  alone;  some  6  per  cent,  of  the  cases  are  on  both  sides,  and 
some  7  per  cent,  of  the  cases  are  on  the  right  side  alone.  The  left  side 
is  affected  more  commonly  because  the  left  spermatic  vein  empties  at 
some  disadvantage  into  the  left  renal  vein  and  not  into  the  vena  cava, 
as  does  the  right  spermatic  vein.  Moreover,  the  left  spermatic  vein 
lies  beneath  the  sigmoid  flexure,  which,  when  loaded,  presses  upon  and 
tends  to  obstruct  it.  It  is  hard  to  say  just  what  is  the  immediate  cause 
of  varicocele,  though  numbers  of  patients  have  a  story  to  tell  of  sudden 
violent  strain  preceding  the  appearance  of  the  lesion.  The  varix  may 
be  trifling  or  extensive;  when  extensive,  it  involves  all  the  veins  of  the 
cord  and  their  tributaries,  from  the  external  ring  to  the  bottom  of  the 
scrotum — and  the  swelling  may  be  obvious  and  considerable.  Men  so 
afflicted  complain  of  various  symptoms — of  a  sense  of  weight  and  drag- 
ging in  the  scrotum,  groin,  and  lumbar  region,  and  sometimes  of  actual 
pain  when  standing  and  on  exertion.  Some  men,  especially  neurotic 
persons,  describe  a  loss  of  sexual  vigor  and  pain  on  coitus.  These  sexual 
symptoms  are  accepted  among  the  laity  as  the  traditional  s3'mptoms  of 
varicocele,  so  that  the  surgeon  is  inclined  to  believe  the  annoyance  is 
often  as  much  a  mental  as  a  physical  one. 

The  diagnosis  is  easy.  The  condition  is  a  disease  of  young  manhood ; 
the  patient  tells  often  of  the  sudden  onset  of  a  swelling,  and  the  surgeon 
finds  a  characteristic  collection  of  enlarged,  tortuous,  more  or  less  elon- 
gated and  corded  veins,  which  are  commonly  described  as  feeling  "  like 
a  bunch  of  worms."  One  must  differentiate  varicocele  from  h3^drocele, 
which  presents  a  smooth,  \miform  enlargement,  from  hydrocele  of  the 
cord,  which  is  smooth  and  fusiform ;  and  from  inguinal  hernia,  which  is 
smooth,  varying  in  size  and  characterized  by  an  impulse  on  coughing. 

I  said  that  the  varices  may  be  cured  by  cutting  out  the  veins.  Some- 
times, in  case  the  varix  is  small,  the  surgeon  may  prefer  to  tie  off  subcu- 
taneously  tw'o  or  three  of  the  veins.  This  method  is  not  surely  cura- 
tive.    A  satisfactory  operation  is  to  lay  bare  the  cord  in  the  groin,  and 


TUMORS    OF   THE    TESTICLE 


475 


to  dissect  out  the  veins,  leaving  one  or  two  small  vessels  only,  and  avoid- 
ing carefully  injury  to  the  vas.  In  the  case  of  greatly  distended  veins, 
which  enlarge  the  scrotum  downward,  it  may  sometimes  be  necessary 
to  amputate  part  of  the  scrotum  with  the  veins.  When  this  is  to  be 
done,  the  testes  must  be  pushed  snugly  up  toward  the  groin,  when  the 
scrotum  may  be  clamped  across  and  trimmed  off  and  the  stump  sewed 
up.    Many  operations  for  varicocele  are  satisfactory  in  the  end,  especially 


Fig.  307. — Subcutaneous  tying  of  varicocele. 

on  account  of  the  relief  from  mental  and  sexual  annoyance  which  they 
afford  the  patient.  I  prefer  the  high  operation — cutting  dovsTi  upon  the 
cord  in  the  groin  and  removing  a  section  of  enlarged  veins  there. 


TUMORS  OF  THE  TESTICLE 

Tumors  of  the  testicle  are  interesting  to  the  pathologist  especially; 
for  there  is  no  organ  of  the  body  in  which  there  are  so  many  varieties  of 
structure  as  in  the  testicle.  Accordingly,  one  finds  there  new-growths 
appearing  at  all  ages.  There  are  three  principal  types  of  these  tumors: 
(1)  Connective-tissue  growths;  (2)  epithelial  tumors;  (3)  dermoid  c^'sts 
and  teratomata.^ 

^  An  excellent  brief  clinical  resume  of  these  tumors  is  Sarcoma  of  the  Testicle, 
A.  L.  "Wolbarst,  Jour.  Amer.  Med.  Assoc,  April  6,  1907. 


47C  GEXITO-URIXARY   ORGANS 

Of  the  first  group,  there  are  benign  and  mahgnant  specimens — fibro- 
mata, lipomata,  niyxomata,  enchondromata,  osteomata,  and  myomata. 
None  of  these  tumors  are  common.  They  may  be  found  in  children, 
and  the  surgeon  should  remove  them,  while  sparing  as  much  as  possible 
of  the  testicle  and  its  associated  structures. 

Sarcomata  are  not  especially  uncommon.  They  begin  usually  in 
the  globus  minor,  and  may  progress  slowly  or  rapidly.  Some  are  soft 
and  of  quick  development;  some  are  hard  and  may  remain  apparently 
quiescent  for  a  long  time.  The  shape  of  the  testicle  may  remain  fairly 
normal,  or  it  may  take  on  a  nodular  outline.  The  round-celled  sar- 
comata are  of  the  more  rapid  growth.  The  spindle-celled  variety  are 
firmer,  and  often  contain  striated  muscle-fibers.  Sarcomata  may  not 
cause  any  great  pain,  though  frequently  they  do  so  in  their  more  advanced 
stages.  If  one  testicle  only  is  attacked,  sexual  vigor  is  not  lost  to  the 
patient.  The  differential  diagnosis  is  difficult  and  sometimes  impossible. 
A  long-standing  hard  nodule  in  the  epididymis  is  suspicious,  especially 
if  it  takes  on  suddenly  a  rapid  growth.  Sometimes  there  is  breaking 
down  of  the  organ  with  necrosis,  hemorrhage,  and  mucoid  softening. 
Late  in  the  disease  the  cord  and  inguinal  glands  are  involved.  The 
surgeon  must  distinguish  sarcoma  from  cancer,  which  occurs  in  middle 


Fig.  308. — Keyes'  needle  for  subcutaneous  ligation  of  varicocele  (Fowler's  Surgery). 

life  or  later,  while  sarcoma  may  be  a  disease  of  childhood, — from  tuber- 
culosis, which  is  characterized  by  softening  and  early  fistula  formation; 
and  from  syphilis,  which  closeh'  resembles  sarcoma  and  often  can  be  dis- 
tinguished from  it  by  its  reaction  to  a  course  of  potassium  iodid  only. 

Obviously,  the  only  radical  treatment  for  sarcoma  of  the  testicle  is  its 
complete  excision,  with  dissection  of  the  cord  and  the  inguinal  lymph- 
nodes  on  the  side  affected. 

Cancer  of  the  testicle  is  the  important  tumor  of  the  epithelial  group. 
It  develops  in  the  testis  itself  and  grows  rapidly.  It  causes  earlier  and 
more  severe  pain  than  does  sarcoma.  The  epididymis  is  involved  late, 
but  the  disease,  as  a  whole,  develops  more  rapidly  than  does  sarcoma. 
The  growth  may  involve  the  skin,  so  that  the  patient  may  present  a 
foul,  ugly,  cauliflower  tumor.  Obviously,  complete  extirpation  of  the 
growth  and  the  adjacent  glands  is  the  only  rational  treatment. 

Adenoma  of  the  testicle  occurs  in  children  and  in  adults.  The  tumor 
grows  rapidly  without  pain,  and  may  reach  the  size  of  a  child's  head. 
Commonly,  it  contains  cysts.  It  is  smooth,  firm,  and  elastic.  The  prog- 
nosis is  uncertain,  because  adenoma  may  be  associated  with  cancer  and 
sarcoma.     Castration  is  the  only  remedy. 

Dermoid  cysts  and  teratomata  are  not  especially  common,  and 


CASTRATION  4// 

usually  begin  to  develop  in  infancy.  They  grow  to  considerable  size 
without  causing  pain,  and  may  be  carried  for  many  years.  They  re- 
semble adenomata  often,  but  appear  at  an  earlier  age  and  contain  em- 
bryonic structures — atheromatous  fluid  with  hair,  teeth,  and  bone.  As- 
piration or  the  .r-ray  will  confirm  the  diagnosis  often.  Sometimes  one 
ma}'  remove  the  tumor  and  save  the  testicle,  but  frequently  castration 
must  be  our  rrsort. 

TWISTED  CORD 

Twisted  cord,  or  strangulation  of  the  cord  by  axial  rotation,  occasion- 
alh'  is  seen — a  curious  and  interesting  condition.  It  is  analogous  to 
twisting  of  the  pedicle  of  an  ovarian  cyst.^  The  condition  is  so  unusual 
that  an  error  in  diagnosis  readily  may  be  made.  The  cause  of  the  twist- 
ing is  not  obvious,  though  in  eveiy  reported  case  there  has  been  a  long 
mesorchium.  A  normally  placed  normal  testicle  is  not  likely  to  suffer 
torsion.  The  symptoms  are  sudden,  and  follow  violent  exertion  usualh'. 
There  may  be  a  hernia  present.  As  a  result  of  the  rotation  the  vessels 
in  the  cord  are  strangulated,  so  that  the  testicle  swells  and  quickly 
becomes  the  seat  of  hemorrhage,  necrosis,  and  gangrene  even.  There 
are  sudden  pain,  vomiting,  shock,  a  swelling  in  the  groin,  and  a  swollen 
testicle  readily  obvious.  There  is  no  impulse  on  coughing.  The  condi- 
tion simulates  strangulated  hernia,  from  which  it  must  be  distingiushed. 
The  treatment  is  by  immediate  operation.  If  the  strangulation  is  recent, 
it  may  be  relieved  by  untwisting  the  cord,  but  in  most  cases  the  testicle 
is  found  gangrenous,  so  that  castration  must  be  done. 

Such  are  the  tumors  and  swellings  of  the  testicle.  Their  diagnosis 
is  difficult  often,  but  their  treatment  is  almost  invariably  by  the  opera- 
tion of  castration. 

CASTRATION 

In  the  case  of  malignant  disease,  castration  should  include  the 
whole,  or  a  large  part  of,  the  scrotum.  In  the  case  of  non-mahgnant 
disease,  the  tumor  may  be  turned  out  of  the  scrotum  through  an  incision 
in  the  groin.  In  either  case,  when  the  dissection  is  completed  and  the 
tumor  mass  is  free  and  left  hanging  by  the  cord  as  a  pedicle,  the  final 
section  of  the  cord  must  be  made  carefully.  Do  not  roughly  tie  it  off 
and  cut  it  en  masse.  Such  treatment  pinches  nerves  and  fails  securely 
to  control  vessels.  Pain  ensues,  and  secondary  hemorrhage  may  take 
place  as  the  cord  slips  back.  Properly  to  amputate  the  cord,  dissect 
carefully  across  it  toward  the  abdominal  cavity,  tying  the  individual 
vessels  as  j^ou  go;  then  stitch  the  stump  into  the  internal  ring.  After 
castration  the  patient  should  be  kept  quiet  in  bed  for  two  weeks  at  least, 
that  healing  may  progress  properly  and  that  no  hernia  may  develop. 
See  article  by  Charles  L.  Scudder,  Ann.  Surg.,  August,  1901. 


PART  IV 

THE  CHEST 


CHAPTER  XVI 

THE  BRONCHI  AND  LUNGS 

Hitherto  in  this  book  we  have  studied  regions  and  structures  readily 
accessible  to  the  surgeon,  but  in  large  part  become  accessible  during  the 
last  thirty  years  only.  We  have  been  considering  the  diseases  of  organs 
associated  with  each  other,  either  in  their  anatomic  relations  or  in  their 
functions — the  organs  of  the  abdomen,  the  genito-urinary,  and  the 
sexual  apparatus.  The  surgeons  of  two  generations  or  more  ago  dealt 
timidly  with  organs  within  the  abdominal  cavity,  and  somewhat  fear- 
fully with  the  bladder,  kidneys,  and  testicles  even,  because  those  sur- 
geons knew  not  how  to  eliminate  sepsis.  The  abdominal  cavity  especi- 
ally was  an  unknown  land  to  most  of  them.  Our  present  measure  of 
success  in  dealing  with  these  organs  is  known  to  all  the  world. 

In  these  days  we  are  turning  our  attention  to  a  new  field — surgery  of 
the  thoracic  cavity.^  We  are  approaching  this  field  with  some  hesi- 
tation, though  with  less  timidity  than  our  forbears  felt  when  they 
approached  the  abdomen.  The  dangers  in  this  new  work  are  not  the 
dangers  which  confronted  pioneers  in  abdominal  surgery.  They  feared 
sepsis  because  they  knew  not  what  it  meant  or  how  to  combat  it.  We 
understand  sepsis,  and  usually  combat  it  with  success;  but  in  thoracic 
surgery  we  must  face  dangers  peculiar  to  the  thorax  and  peculiarly 
difficult  to  meet.  When  we  open  the  thorax,  we  have  to  deal  with  organs 
the  wounding  of  which  promptly  is  serious,  if  not  fatal — organs  incased 
in  an  unyielding  cage,  organs  not  readily  accessible,  of  varying  con- 
sistency and  dimensions,  easily  escaping  from  operative  control.  In 
the  abdomen  you  may  excise  the  intestines  and  stomach,  open  widely 
the  liver,  or  remove  the  spleen ;  indeed,  many  of  the  abdominal  organs 
can  be  eliminated  without  danger  to  life.  The  intrathoracic  organs, 
on  the  other  hand,  must  be  approached  cautiously,  opened  with  hesita- 
tion, if  at  all,  and  totally  removed  never.  But  one  must  not  think  of 
these  organs  in  the  chest  as  inaccessible  to  surgeons.  Constantly,  with 
increasing  knowledge,  we  are  more  certainly  cutting  down  upon  the 
lungs,  the  bronchi,  and  the  heart;  and  with  increasing  experience  we  are 
learning  the  possibilities  of  intrathoracic  surgery  and  the  extent  of  our 
1  See  Trans.  Amer.  Surg.  Assoc,  1909. 
478 


FOREIGN    BODIES    IN  THE   BRONCHI  479 

limitations.  There  is  one  exception  to  the  novelty  of  operating  for 
diseases  within  the  chest — empyema  and  other  pleuritic  collections  have 
been  subject  to  operation  since  the  time  of  Hippocrates. 

When  we  consider  diseases  of  the  bronchi  and  lungs,  we  must  think  of 
the  whole  complicated  apparatus  which  extends  from  the  bifurcation  of 
the  trachea,  opposite  the  third  dorsal  vertebra,  through  the  primary, 
secondary,  and  terminal  bronchi  and  the  whole  structure  of  the  lungs, 
with  their  intricate  arrangement  of  alveoli,  bronchioles,  and  network  of 
important  vessels,  all  bounded  by  the  visceral  pleura.  Within  this  com- 
phcated  mechanism  the  surgeon  operates  for  the  following  lesions 

Foreign  bodies  in  the  bronchi. 

Bronchiectasis. 

Pulmonary  abscess. 

Pulmonary  gangrene. 

Hemothorax. 

Tuberculosis. 

Tumors. 

Echinococcus  cysts. 

Actinomycosis. 

Aneurysm. 

FOREIGN  BODIES  IN  THE  BRONCHI 

Foreign  bodies  in  the  bronchi  were  regarded  as  fatal  up  to  a  few 
years  ago — fatal,  if  the  foreign  body  lodged  and  could  not  be  coughed  up. 
Then  sundry  surgeons  devised  ingenious  measures  for  opening  the  pos- 
terior or  anterior  mediastinum  and  performing  bronchotomy.  But  these 
operations  are  difficult,  with  a  mortality  of  almost  100  per  cent.  In  more 
recent  years  surgeons  who  have  concerned  themselves  especially  with 
work  upon  the  throat  and  trachea  have  devised  instruments  by  means  of 
which  foreign  bodies  in  the  bronchi  may  be  discovered  and  removed 
through  the  mouth  or  through  a  tracheotomy  opening.^ 

The  objects  w^hich  reach  the  bronchi  must  be  small  enough  to  pass 
between  the  vocal  cords,  whence  they  drop  into  the  right  bronchus 
commonly,  since  that  is  given  off  from  the  trachea  at  a  less  acute  angle 
than  is  the  left.  Coins  and  buttons  are  the  objects  most  frequently  in- 
haled, and  usually  by  children.  More  than  one  case  of  a  loosened 
tracheotomy  tube  discovered  in  the  bronchus  has  been  reported,  and 
Coolidge  pictures  pins  and  a  carpenter's  nail,  while  D.  W.  Cheever 
graphically  describes  a  beard  of  wheat  flying  up  and  down  with  res- 
piration. 

The  lodgment  of  these  foreign  bodies  induces  a  variety  of  symptoms. 
If  the  object  is  small  and  does  not  become  immediately  impacted,  the 
patient  experiences  a  sense  of  suffocation.  He  coughs,  strangles,  and 
may  vomit.  There  may  be  pain  in  the  chest,  with  bloody  expectoration. 
Again,  the  object  may  completely  plug  a  bronchus,  thus  throwing  out 

1  A.  Coolidge,  Jr.,  Boston  Med.  and  Surg.  Jour.,  April  10,  1902;  von  Eichen, 
Arch.  f.  Laryng.,  Bd.  xv,  3.  Heft.;  A.  Coolidge,  Jr.,  Boston  Med.  and  Surg.  Jour., 
October  13,  1904;  Carl  Beck,  Surgical  Diseases  of  the  Chest,  1907,  p.  239  et  seq. 


480  THE    CHEST 

of  commission  a  portion  of  the  lung.  This  is  an  extremely  rare  con- 
dition. If  the  body  remain  long  impacted,  there  may  result  a  bronchitis, 
with  asthma,  or  a  pneumonia  even;  and,  most  serious  of  all,  perhaps, 
pulmonar}^  abscess  or  gangrene  of  the  lung. 

These  foreign  bodies  lodge  in  the  right  bronchus,  as  I  have  stated,  and 
the  surgeon  locates  them  first  by  means  of  the  x-ray.  Then,  with  the 
bronchoscope  (Coolidge  recommends  KilHan's)  passed  either  through 
the  mouth  into  the  trachea  or  through  a  tracheotomy  opening,  the 
patient  being  under  ether  anesthesia,  an  expert  may  discover  a  foreign 
body  and  extract  it  with  Killian's  force]>s.  I  have  seen  Coolidge  do  a 
number  of  these  operations  rapidly  and  dexterously,  but,  as  a  general 
surgeon,  I  have  never  undertaken  them. 

BRONCHIECTASIS 

Bronchiectasis  (iDronchial  dilatation)  is  one  of  the  intrapulmonary 
ailments  for  which  rarely  surgeons  have  operated.  There  is  no  great 
enthusiasm  for  this  operation,  but  occasionally  it  seems  justifiable,  and 
several  successful  cases  have  been  reported.  There  are  various  forms  of 
bronchial  dilatation — the  cylindric  form,  in  which  a  single  t»ranch  or  sev- 
eral branches  of  the  smaller  or  medium-sized  bronchi  are  involved ;  the 
dilatation  of  a  large  bronchus  alone,  and  a  terminal,  sac-like  bronchiecta- 
sis, developing  at  the  expense  of  the  lung  parenchyma.  Grawitz  reports 
a  case  of  congenital  bronchiectasis  in  which  one  of  the  lower  pulmonary 
lobes  had  been  changed  to  a  lax  sac  with  many  cavities.  In  any  case 
of  bronchiectasis  there  may  be  a  concurrent  tuberculosis.  Note  es- 
pecially the  chronic  thickenings  of  the  pleura  which  frequently  accom- 
pany or  are  associated  wath  bronchiectasis.  In  any  form  of  bronchiectasis 
the  disease  nms  a  chronic  course.  The  first  symptom  is  a  paroxysmal 
cough,  most  troublesome  in  the  morning;  and  the  cough  frequent I3'  is 
associated  with  violent  expectoration,  when  the  patient  may  raise  a 
great  amount  of  sputum — often  several  cupfuls — suggesting  the  rup- 
ture of  an  empyema  into  a  bronchus.  The  sputum  may  stink,  or  it 
may  be  odorless,  and  it  is  often  mixed  with  blood.  It  is  needless  to  dwell 
in  detail  on  the  various  symptoms  of  this  condition,  but  the  diagnosis 
may  be  made  by  physical  examination.  Percussion  and  auscultation 
usually  demonstrate  signs  of  a  cavity.  There  may  be  more  or  less  dul- 
ness,  followed  by  a  resonant,  tympanitic  note,  depending  on  the  amount 
of  contents  in  the  bronchial  cavity,  and  the  change  of  percussion-note 
is  striking  also  as  the  patient  opens  or  closes  his  mouth  or  changes  his 
position.  At  times  one  hears  nothing  on  auscultation;  at  other  times 
one  may  discover  bronchial  breathing,  with  coarse  moist  rales.  Some- 
times the  x-rsiy  will  confirm  a  diagnosis.  Serious  complications  of 
bronchiectasis  are:  purulent  bronchitis,  catarrhal  pneumonia,  gangrene 
of  the  lung,  abscess  of  the  brain,  and  meningitis.  Emphysema  is  fre- 
quent and  important. 

The  treatment  of  bronchiectasis  is  nearly  always  symptomatic,  but 
Tuffier,  in  his  classic  monograph,  reported  46  cases  with  39  operations, 


GENERAL   TECHXIC   OF   OPERATIXG    UPOX  THE    LUNGS  481 

and  of  these  patients  10  died,  while  29  recovered.  Numerous  other 
reporters  show  similar  statistics.  The  cases  suitable  for  operation  are 
those  in  which  there  is  a  great  dilatation  of  one  bronchus  only,  and  the 
procedure  consists  in  opening  and  draining  the  cavity.  Those  patients 
who  have  been  improved  or  have  recovered  certainly  have  experienced 
great  relief,  so  that  we  believe  the  operation  for  bronchiectasis  must 
seriously  be  regarded  as  an  important  therapeutic  measure.  So  much 
for  the  surgery  of  the  bronchi  as  hitherto  it  has  developed.  Before 
going  further  into  the  discussion  of  intrathoracic  surgery  let  us  consider 
the— 

GENERAL  TECHNIC  OF  OPERATING  UPON  THE  LUNGS 

Pneumonotomy  obviously  means  opening  into  the  lung;  pleurotomy 
is  an  incision  into  the  pleura.  These  are  two  common  terms  with 
which  we  are  concerned,  though  Ricketts,  in  his  well-kno^^-n  book,  gives 
a  list  of  some  55  special  terms  dealing  with  the  pathology  and  treat- 
ment of  lung  and  pleural  diseases.^ 

Surgeons  maintain  the  importance  of  occasional  exploratory  opera- 
tions to  determine  the  exact  nature  and  location  of  diseases  within  the 
chest,  although  the  a:-ray  has  rendered  such  explorations  less  imperative 
than  they  were.  The  student  should  remember  that  the  right  primary 
bronchus  descends  into  the  lungs  at  a  less  acute  angle  than  does  the 
left;  that  the  right  lung  is  made  up  of  three  lobes,  and  the  left  lung  of 
two  lobes,  while  the  extent  of  the  thoracic  viscera  is  from  the  apex  of 
the  lungs  about  an  inch  above  the  level  of  the  first  rib,  to  the  base  af  the 
lungs,  which  rests  upon  the  convexity  of  the  diaphragm;  while  the  heart, 
pericardium,  and  large  vessels  occupy  an  important  space  in  the  superior 
and  anterior  left  central  portions  of  the  chest.  The  mechanical  ob- 
stacles to  operations  within  the  pleural  cavity  are,  first  and  most  im- 
portant, collapse  of  the  corresponding  lung,  when  the  chest  is  opened, 
with  pneumothorax;  and  the  presence  of  a  large,  stiff-w^alled  cavity. 
Most  writers  have  maintained  that  adhesions  existing  between  the  pari- 
etal and  ^dscera^pleura  are  necessary  in  order  that  one  may  operate  suc- 
cessfully upon  the  lung,  because  through  such  adhesions  the  surgeon 
may  penetrate  without  danger  of  infecting  the  surrounding  and  uncon- 
taminated  pleura.  There  are  various  methods  of  entering  the  chest, 
the  two  most  important  being — (1)  Through  a  small  opening,  bj-  the 
removal  of  portions  of  one  or  two  ribs  over  the  supposed  site  of  the  lesion, 
and  (2)  the  turning  back  of  a  large  osteoplastic  flap,  as  in  Schede's 
operation  for  empyema.  When  the  large  flap  is  to  be  turned  back, 
the  surgeon  should  make  a  wide,  U-shaped  skin  incision,  going  down 
directly  upon  the  ribs  over  the  lower  part  of  the  thorax  in  the  posterior 
axillary  region,  and  resecting  broadly  portions  of  several  ribs — generally 
the  sixth,  seventh,  eighth,  and  ninth.  By  this  means  a  large  free  open- 
ing is  secured,  which  enables  the  operator  to  work  with  some  freedom 
inside  the  chest,  to  explore  thoroughly  the  collapsed  lung,  if  it  is  collapsed, 

1  B.  M.  Ricketts,  Surgery  of  the  Heart  and  Lungs,  1904,  pp.  279-281. 
31 


482 


THE   CHEST 


and  to  establish  depondont  drainage.  Before  opening  the  hing,  but  after 
having  laid  bare  the  visceral  pleura,  the  suregon  may  wall  oil  the  held 
of  operation  with  iodoform  gauze  tampons,  or  he  may  provide  against 
infection  by  drawing  up  the  collapsed  lung  against  the  chest-wall 
and  fastening  it  there  with  deeply  placed  catgut  stitches  in  order  to 
bring  about  atlhesions  at  that  point.  This  latter  UK^thod  is  advocated 
by  many  experienced  operators.'  The  paramount  objection  to  so 
extensive  a  dissection  lies  in  the  fact  that  most  of  the  patients  sub- 
mitted to  pneumonotomy  are  in  wretched  physical  condition,  little 
able  to  endure  the  shock  of  a  prolonged  operation.     For  this  reason 


Fig.  309. — Schede's  incision  for  opening  the  chest. 

the  more  circumscribed  operation  must  often  be  the  operation  of  elec- 
tion. The  technic  of  the  circumscribed  operation  is  simple  enough. 
The  surgeon  approaches  the  chest  through  a  straight  incision  along  a  rib 
over  the  site  of  the  pulmonary  lesion,  and  excises  quickly  bits  of  one  or 
two  ribs.     Frequently  the  lung  is  adherent  to  the  chest-wall  at  the  point 

1  The  FelI-0'Dwyer  apparatus  for  inflating  the  lung  is  advocated  by  Matas  and 
DaCosta.  It  is  in  principle  a  competent  bellows,  by  the  means  of  which  air  is  forced 
into  the  lungs.  The  O'Dwyer  tube  is  introduced  into  the  glottis  and  the  bellows 
is  worked  by  foot-power.  This  instrument  is  moderately  successful  in  preventing 
collapse  of  the  lung.  F.  T.  Murphy  also  has  demonstrated  an  apparatus  which  acts 
on  the  principle  of  the  Brauer  positive  pressure  apparatus. 


GENERAL  TECHNIC  OF  OPERATING  UPON  THE  LUNGS     483 

of  attack.  If  it  is  not,  the  pleural  cavity  must  be  guarded  by  tampons 
or  stitching.  However  the  lung  is  reached,  when  it  is  reached  it  remains 
for  the  operator  to  search  the  affected  pulmonary  area.  In  regard  to 
this  searching  again,  surgeons  have  differed  in  their  methods,  some  usmg 
a  long,  narrow-bladed  knife,  others  the  cautery,  and  others  the  finger 
supplemented  by  instruments.  I  advocate  the  last  method,  as  it  is  less 
likely  to  damage  lung  tissue,  and  it  obviates  troublesome  hemorrhage. 
Most  of  these  operations  give  rise  to  more  or  less  pneumothorax,  but 
this  is  a  bugbear  not  seriously  to  be  considered.  Such  operative  pneu- 
mothorax usually  takes  care  of  itself,  especially  if  the  operation  and 
dressings  are  done  with  the  lung  inflated,  either  by  the  Sauerbruch 
cabinet,  or  by  W.  Meyer's  or  Robinson's  differential  pressure  apparatus. 
Methods  of  artificial  respiration  in  lung  surgery  have  not  been  com- 
monly adopted  up  to  the  time  of  this  writing,  but  it  is  probable  that 


Yi<r.  310.— Sauerbruch's  cabinet.     Position  of  patient  in  chamber  ready  for  opera- 
'^  tion  under  negative  pressure. 

before  many  years  all  surgeons  will  follow  the  lead  of  the  advanced 
investigators  in  employing  invariably  some  form  of  pulmonary  pressure 
apparatus  whenever  they  open  the  chest.  At  this  time  it  seems^that 
the  Sauerbruch  pneumatic  cabinet  has  made  the  best  showing."-^  In 
regard  to  the  Sauerbruch  cabinet,  W.  Meyer  observes  strikingly:  '  The 
beauty  of  this  cabinet  is  that  it  can  be  used  for  negative  as  well  as 
positive  pressure.  If  the  operation  with  negative  pressure  is  desired, 
the  patient's  head  is  placed  outside  the  cabinet  and  the  body  inside; 
if  positive  pressure  is  desired,  the  head  is  placed  inside  and  the  body  out- 
side. In  either  case  the  anesthetist  has  free  access  to  the  patient  s 
head.     If  he  is  inside  the  cabinet  and  positive  pressure  is  used,  the 

1  J.  G.  Mumford,  Artificial  Respiration  and  Operations  Within  the  Thorax,  Bos- 
ton Med.  and  Surg.  Jour.,  December  3  and  10,  1908. 


484  THE   CHEST 

excellent  ventilation  provided  fur  will  prevent  his  becoming  anesthetized 
himself." 

Says  Sauerbruch:  "  So  far  as  the  anesthetic  is  concerned,  it  is  re- 
markable how  small  a  C}uantity  is  needed  to  produce  complete  anes- 
thesia, and  then  only  at  the  time  of  opening  and  closing  the  thoracic 
cavity.  .  .  .  It  has  been  shown  that  it  is  unwise  to  reduce  the  pressure 
more  than  7  or  8  mm.  of  mercury,  and  Friedrich  has  had  excellent 
results  with  a  negative  pressure  of  from  3  to  5  mm."  We  see  then  that 
a  very  slight  increase  of  intra]>ulmonary  pressure  is  sufficient  to  keep 
the  lung  expanded  when  the  i)leural  cavity  is  open.  The  steady  expan- 
sion of  the  lung  is,  of  course,  an  enormous  assistance  in  operating  upon 
that  organ  itself,  while  at  the  same  time  it  insures  the  most  thorough 
evacuation  of  the  chest  when  the  pleural  cavity  is  opened  to  drain  fluids, 
Sauerbruch  dwells  especially  upon  the  usefulness  of  his  cabinet  when 
one  operates  for  empyema,  and  after  all  intrathoracic  operations,  when 
the  wounds  are  dressed,  and  says  further:  "  All  recent  empyemas  and 
a  considerable  percentage  of  the  chronic  ones  yield  quickly  without  the 
formation  of  a  fistula;  the  patient  is  spared  tedious  after-treatment  and 
subsequent  plastic  procedures." 

The  first  and  one  of  the  most  accessible  lesions  for  which  we  operate 
is  abscess  of  the  lung.^  This  condition  is  not  common.  It  may  com- 
plicate lobar  pneumonia  or  influenza  pneumonia,  or  may  occur  suddenly 
in  lung  tissue  previously  healthy,  from  embolism,"  from  the  lodgment 
of  a  foreign  body,  or  as  a  complication  of  some  such  systemic  infection  as 
puerperal  fever.  The  syv^ptoms  may  be  obscure,  or  they  maj"  be  char- 
acteristic. The  condition  is  most  often  mistaken  for  a  patch  of  pneu- 
monia or  for  a  localized  empyema.  The  condition  of  the  sputum  is  the 
best  indication  of  abscess,  and  the  sputum  may  be  coughed  up  in  large 
quantities — sometimes  as  pure  pus,  sometimes  moldy,  with  a  sour  or 
sweetish  odor,  sometimes  fetid.  Under  the  microscope  you  will  find 
connective-tissue  and  elastic  fibers,  and  occasionally  a  deposit  of  black 
pigment,  with  fatty  crystals  and  hematoidin  crystals.  The  diagnosis 
often  is  difficult  in  the  absence  of  the  characteristic  expectoration.  After 
an  attack  of  coughing  look  for  a  tympanitic  note  over  an  area  previously 
dull.  Abscess  of  the  lung  may  be  confused  with  gangrene  also,  but  in 
gangrene  the  expectoration  is  extremely  foul,  and  elastic  fibers  usually 
are  absent.  The  outlook  in  these  abscess  cases  is  grave,  though  statis- 
tics appear  to  show  that  the  best  outcome  in  the  case  of  pulmonary 
abscess  follows  abscess  due  to  pneumonia.  Medical  treatment  some- 
times results  in  recovery,  but  if  the  abscess  persists,  especially  if  it  is 
progressive,  the  physician  should  seek  surgical  advice  with  a  view 
to  operation.  I  have  already  described  the  technic  of  searching  the 
lung  for  abscess.  It  is  necessary  to  establish  competent  drainage  when 
the  abscess  is  found,  and  for  this  purpose  there  is  nothing  better  than  a 

1  See  important  case  described  by  C.  H.  Cottle  and  J.  R.  Edward  in  Brit.  Med. 
Jour.,  March  7,  1908. 

-  Trendelenburg's  case,  Deut.  med.  Woch.,  July  2,  1908,  quoted  in  Practical  Medi- 
cine Series,  vol.  ii,  p.  215,  series  of  1909. 


GENERAL  TECHNIC   OF   OPERATING    UPON   THE    LUNGS  485 

rubber  tube  wrapped  in  guuzc.  The  drain  should  be  changed  every 
two  or  three  days,  lest  it  cause  ulceration  of  a  pulmonary  vessel  and 
give  rise  to  serious  hemorrhage.  Several  accidents  of  this  nature  have 
been  reported.  The  results  of  treatment  depend  somewhat  on  the  nature 
of  the  abscess.  Pneumonia  or  influenza  abscesses  promise  well,  but 
abscess  due  to  the  lodgment  of  a  foreign  body  is  almost  never  found. 
The  drainage,  dressings,  and  supplementary  care  of  the  patient  must  be 
continued  for  a  long  time  often,  and  so  soon  as  may  be  the  patient  should 
be  given  an  out-of-doors  life. 

Gangrene  of  the  lung  is  closely  associated  with  abscess  of  the  lung 
in  its  origin  and  physical  signs.  I  have  told  already  how  the  foul  char- 
acter of  the  sputum  differentiates  it  from  abscess.  Gangrene  is  a 
necrosis  of  lung  tissue,  produced  by  putrefactive  bacteria,  and  is  either 
circumscribed  or  diffuse.  It  is  more  rare  than  abscess.  The  common 
factors  in  its  etiology  are  lobar  pneumonia  and  pneumonia  due  to  a 
foreign  body.  Sometimes  it  is  preceded  by  an  infarction.  Alcoholic 
and  diabetic  subjects  are  the  persons  especially  subject  to  pulmonary 
gangrene.  I  have  already  described  the  treatment,  which  is  similar  to 
that  for  pulmonary  abscess.  Circumscribed  gangrene  is  the  only  form 
of  gangrene  amenable  to  surgical  treatment.  When  the  diagnosis  is 
assured,  the  surgeon  should  insist  upon  operation,  for  spontaneous 
recovery  is  improbable. 

Pulmonary  tuberculosis  at  times  has  come  within  the  purview  of  the 
surgeon,  but  such  tuberculosis  must  be  localized.  A  large  number  of 
operators  in  France  and  Germany  have  made  experiments  in  this  field, 
but  such  work  has  not  yet  appealed  greatly  to  American  surgeons.  The 
method  is  to  attack  small  localized  tuberculous  processes  or  cavities  by 
injections  of  iodoform  oil  or  by  actual  excision  (pneumonectomy), 
with  drainage.  The  excision  should  be  made  with  the  cautery.  In  all 
probability  this  method  will  fall  into  disuse  before  the  superior  advan- 
tages of  hygienic  treatment  and  the  employment  of  the  opsonins. 

Echinococcus  of  the  lung  is  fairly  amenable  to  surgical  treatment, 
and  the  lung,  after  the  liver,  is  the  organ  most  frequently  attacked  by 
echinococci.  There  is  but  one  cyst  cavity  in  the  lung,  as  a  rule,  and  this 
cavity  may  become  extremely  large,  so  as  to  fill  completely  one  pleural 
sac  and  displace  neighboring  thoracic  and  abdominal  organs.  Strangely 
enough,  small  cavities  may  produce  no  symptoms  for  a  long  time,  but 
large  cysts  induce  sensations  of  tension,  pressure  pains,  and  dyspnea. 
Sometimes  the  cavity  opens  into  a  bronchus,  so  that  the  patient  coughs 
up  great  quantities  of  pus  and  organisms.  Unless  the  organism  has  been 
discovered,  it  is  impossible  to  make  the  diagnosis.  The  organism  may  be 
isolated  from  the  sputum  or  may  be  secured  by  aspiration.  Echinococ- 
cus of  the  lung  simulates  pulmonary  tuberculosis,  or,  when  the  cavity 
is  large,  suggests  an  intrathoracic  neoplasm.  The  results  of  surgical 
treatment  have  been  brilliant.  For  instance,  Tuffier  reported  55  recov- 
eries out  of  61  cases.  Simple  aspiration  and  washing  out  of  the  cavity  is 
a  dangerous  procedure,  and  must  be  reprobated,  because  the  cleansing 
fluid  may  flow  into  a  bronchus  and  flood  the  lungs.     The  surgeon  should 


486  THE   CHEST 

institute  abundant  drainage  in  the  manner  I  have  already  described. 
In  most  cases  recovery  is  slow,  but  usually  certain. 

Pulmonary  actinomycosis  demands  a  word  in  passing,  though 
primary  actinomycosis  of  the  lung  is  rare.  It  is  needless  to  describe  in 
detail  the  character  of  the  slowly  advancing  disease,  which  begins 
usually  as  a  destructive  inflammation  about  the  bronchi,  and  involves 
gradually  considerable  areas  of  lung  tissue,  reaching  finally  the  pleura 
and  involving  the  skin,  where  it  manifests  itself  in  swellings  and  sinuses. 
The  disease  is  mistaken  commonly  for  tuberculosis.  The  few  operations 
undertaken  hitherto  have  been  limited  to  opening,  cureting,  and  drain- 
ing sinuses  and  abscesses.     Very  few  cures  are  reported. 

Cancer  of  the  lung  (primary)  does  not  seem  to  be  especially  rare, 
but  its  diagnosis  is  so  difficult  that  operative  treatment  must  be 
uncommon.  It  is  mistaken  for  tuberculosis,  chronic  pneumonia,  and 
pleurisy,  though  the  x-ray  may  give  valuable  information  as  to  its 
character.  Circumscribed  tumors,  as  large  as  a  hen's  egg  even,  rarely 
can  be  detected  unless  they  are  on  the  surface  of  the  lung.  Occasion- 
ally bits  of  the  tumor  in  the  sputum  have  furnished  evidence  on  which 
to  found  a  diagnosis.  Seldom  is  there  a  ])louritic  effusion,  because  the 
pleurae  become  adherent.  The  ordinary  physical  examination  suggests 
merely  a  localized  consolidation  of  lung  tissue,  but  the  wasting  and  ca- 
chexia, with  the  examination  of  the  sputum,  may  determine  the  diag- 
nosis. Advanced  cases  of  pulmonary  cancer  cannot  be  cured,  but  a  few 
instances  are  reported  in  which  small  circumscribed  ]3ulmonary  growths 
associated  with  tumors  of  the  chest-wall  have  been  removed  successfully. 
The  Sauerbruch  cabinet  is  an  important  aid  in  such  work. 

Sarcoma  of  the  lung  is  less  common  than  cancer.  The  spindle- 
cell  variety  is  seen  occasionally,  though  a  rare  form  of  lymphosarcoma 
is  described.  The  symptoms  are  misleading.  As  in  the  case  of  cancer, 
there  is  pain  in  the  side,  and  a  sense  of  oppression  and  cough,  thought 
to  be  due  to  a  persistent  bronchial  catarrh.  The  sputum  is  not  charac- 
teristic. Metastases  are  more  common  in  sarcoma  than  in  cancer,  and 
appear  as  direct  involvement  of  neighboring  organs.  Surgical  treat- 
ment of  sarcoma  is  similar  to  that  of  cancer. 

Secondarily  maHgnant  disease  of  the  lungs,  associated  especially 
with  malignant  disease  of  the  breast,  is  always  inoperable. 

The  benign  tumors,  so  familiar  in  other  parts  of  the  body,  are  al- 
most unknown  in  the  lungs  so  far  as  surgeons  have  investigated,  al- 
though such  growths  occasionally  are  found  postmortem. 

Injuries  of  the  lung  are  nearly  always  associated  with  complicat- 
ing injuries  to  the  chest -wall,  and  are  due  to  crushing  blows  or  penetrat- 
ing wounds.  So  far  as  the  lung  is  concerned,  the  interesting  and  sig- 
nificant symptom  to  be  combated  is  hemorrhage.  The  blood  may  be 
expectorated  or  may  fill  the  pleural  cavity  as  hemothorax.  The  treat- 
ment is  conservative  in  most  cases.  The  hemorrhage  is  not  often  alarm- 
ing, and  is  controlled  by  keeping  the  patient  recumbent  and  quiet, 
and  by  snugly  strapping  and  bandaging  the  chest.  Sometimes,  how- 
ever, continued  alarming  hemorrhage  persists,  so  that  it  may  seem  best 


GENERAL  TECHNIC  OF  OPERATING  UPON  THE  LUNGS     487 

to  the  surgeon  to  operate  for  the  purpose  of  controlKng  it.  In  such  cases 
one  should  open  the  chest  widely  through  an  osteoplastic  flap,  should 
wipe  out  the  blood  and  clots  from  the  pleural  cavity,  and  should  seek 
the  bleeding  vessel.  Seldom  can  such  a  vessel  be  tied,  unless  it  is  near 
the  lung  surface,  but  the  wound  may  be  opened  with  the  cautery  and 
packed  with  iodoform  gauze,  so  as  to  control  the  bleeding.  Drainage 
must  be  employed  in  these  cases  also,  and  particular  care  must  be  taken 
to  strap  and  bandage  the  chest  after  the  operation.  The  great  sub- 
sequent distress  of  the  patient  should  be  relieved  by  small  and  fre- 
quently repeated  doses  of  morphin. 


CHAPTER  XVII 

THE  PLEURA 

Diseases  of  the  pleura  are  subject  to  surgical  operations  more  com- 
monly than  any  other  diseases  within  the  thoracic  cage.  I  have  said  that 
Hippocrates  was  cognizant  of  such  operations.  From  his  time  to  the 
present  gradually  an  improved  technic  ha.s  been  evolved,  but  even  yet 
we  cannot  say  that  a  technic  for  operations  upon  the  pleural  cavity  has 
been  perfectetl. 

The  cavity  of  the  pleura  is  of  simpler  anatomic  arrangement  than  is 
the  cavity  of  the  peritoneum,  though  it  is  quite  analogous  to  the  latter. 
The  pleura  is  like  a  huge  lymph-sac  or  bursa,  interposed  between  the 
lung  and  the  chest-wall.  Its  inner  or  visceral  layer  inwraps  closely  the 
lung  and  great  vessels,  while  the  outer  or  parietal  layer  is  stretched  over 
the  inner  wall  of  the  thorax.  The  pleura  has  the  structure  and  functions 
of  other  serous  sacs.  It  is  abundantly  absorbent  of  toxic  products; 
it  secretes  an  abundant  fluid  when  irritated.  \Mien  normal,  its  smooth, 
shining,  inner  surfaces  play  over  each  other  with  the  rise  and  fall  of 
the  chest.  The  ordinary  movements  within  the  pleural  sac  are  far  less 
excursive  than  are  the  movements  within  the  peritoneum,  for  the  play 
of  the  lungs  and  thoracic  wall  is  relatively  slight.  From  such  con- 
siderations the  reader  will  perceive  that  diseases  of  the  pleura,  though 
vital  and  troublesome,  are  not  so  intricate  as  are  diseases  of  the  peri- 
toneum. For  the  sake  of  convenience  let  us  consider  diseases  of  the 
pleura  under  the  following  headings:  Inflammatory  effusions,  hydro- 
thorax,  hemothorax,   chylothorax,   tuberculosis,  and  tumors. 

INFLAMMATORY   DISEASE 

Inflammatory  disease  of  the  pleura  rarely  is  primary.  In  the 
majority  of  cases  it  is  an  extension  from  disease  within  the  lung  or  some 
other  neighboring  organ  or  structure — the  liver,  the  peritoneum,  the 
spinal  column,  the  ribs.  In  recent  years  we  have  found  many  of  these 
so-called  simple  effusions  to  be  tuberculous.  Pneumonia  also  is  a  com- 
mon cause  of  pleuritic  effusion.  "  Catching  cold  "  may  be  a  possible 
cause  of  effusions,  and  it  is  certain  that  many  infections  of  the  pleura 
are  coincident  with  sundry  joint  infections — the  origin  of  both  being 
often  difficult  to  determine,  though  an  invasion  of  organisms  through  the 
tonsils  or  through  the  intestinal  mucosa  frequently  explains  the  trouble. 
Effusions  into  the  pleura  may  be  general  or  may  be  localized  and  pock- 
eted. General  effusions  fill  the  pleural  cavity  affected,  compress  the 
lung  and  heart,  and  bulge  into  the  intercostal  spaces,  so  that  in  ex- 
treme cases  one  lung  is  thrown  out  of  commission  and  the  heart  is 

488 


INFLAMMATORY    DISEASE 


489 


dit?locat,cd.  Localized  or  pocketed  effusions  arc  confined  by  adhesions 
between  the  visceral  and  parietal  pleurae,  so  that  the  collections  impinge 
upon  the  lungs  over  limited  areas  only. 

With  an  understanding  of  the  pathologic  anatomy  the  reader  will 
conceive  at  once  what  must  be  the  symptoms  produced,  though  he  will 
remember  at  the  same  time  how  symptoms  will  vary  with  the  under- 
lying or  associated  conditions — pneumonia,  phthisis,  and  the  like. 
Simple  serous  effusions  cause  mild  symptoms,  as  a  rule.  The  sharp, 
agonizing,  initial  pain  of  pleurisy  precedes  the  effusion,  and  is  due  to  the 
irritating  contact  of  opposed,  dry,  inflamed  layers  of  pleura.  With 
the  onset  of  effusion  the  layers  are  separate  and  pain  is  allayed.  Then 
there  ensue  dyspnea,  a  varying  fever,  and  constitutional  signs. 


r^"**®-.. 


fc>».-^' 


Fis;.  311. — ^Thoracentesis. 


Treatment. — In  a  great  many  cases  these  simple  effusions  are  ab- 
sorbed and  their  treatment  is  within  the  domain  of  the  internist,  with 
whose  examination  of  the  chest,  by  percussion  and  auscultation,  we 
need  not  concern  ourselves  here.  A  considerable  proportion  of  cases 
do  not  improve  under  medication,  but  may  clear  up  quickly  as  the  result 
of  aspiration.  Aspiration  is  best  performed  with  a  trocar,  cannula,  and 
suction  apparatus,  and  the  fluid  withdrawn  should  always  be  examined 
critically  in  order  to  determine  especially  the  presence  in  it  of  pus,  of 
tubercle  bacilli,  or  of  other  organisms.  Sometimes  guinea-pig  inocula- 
tion alone  will  demonstrate  tuberculosis.     The  distinction  between  a 


490  THE   CHEST 

simple  serous  effusion  and  a  purulent  effusion  is  one  of  degree  only. 
The  serous  effusions  contain  few  leukocytes  and  few  organisms. 

As  a  rule,  then,  a  simple  serous  effusion  will  clear  up  after  one  or  two 
aspirations,  provided  the  operator  has  not  infected  the  cavity  at  the 
time  of  aspirating.  When  the  fluid  in  the  chest  has,  become  purulent, 
the  condition  is  one  of  pyothorax. 

PYOTHORAX 

Commonly,  we  speak  of  such  collections  of  pus  as  empyema}  The 
pathologic  and  bacteriologic  conditions  vary  in  empyema,  depending 
on  the  nature  and  source  of  the  organisms.  Pneumococci  in  the  pus 
and  an  associated  pneumonia  are  common  in  children;  pneumococci, 
streptococci,  and  tubercle  bacilli  are  found  at  all  ages.  Sometimes  there 
are  present  organisms  of  decomposition.  The  pneumococcus  pus  is 
creamy  or  light  green  in  appearance,  nearly  odorless,  often  full  of  large 
coagula,  and  easily  disposed  of  by  operation.  The  pus  of  tuberculosis 
nearly  always  is  due  to  a  mixed  infection;  it  may  be  thick  or  thin, 
odorless  or  offensive,  while  the  pus  due  to  saprophytic  bacteria  is  thin 
and  very  foul. 

These  various  collections  of  pus  cause  various  symptoms,  in  their 
turn,  not  differing  materially  in  character  from  the  symptoms  of  a  simple 
effusion — discomfort,  dyspnea,  fever,  and  debility.  But  the  symptoms 
do  not  subside  when  pus  is  present.  Rarely,  nature  may  find  a  vent 
for  the  fluid  through  the  bronchi  or  through  the  chest-wall,  but  generally, 
if  let  alone,  the  process  goes  on.  The  pleura  becomes  more  and  more 
thickened,  the  lung  more  compressed  and  useless,  and  the  thoracic  cage 
fixed  and  deformed,  so  that  in  the  course  of  time  the  patient  presents 
himself  as  an  emaciated,  cripjDled,  gasping,  distorted  invalid. 

One  invariable  rule  must  guide  us  in  the  treatment  of  empyema. 
Drain  the  pus  at  once,  as  soon  as  it  is  discovered.  Discover  it  more 
promptly  than  is  now  done  always.  If  you  have  to  deal  with  a  chest 
which  shows  the  physical  signs  of  fluid,  the  nature  of  which  is  not  ap- 
parent, do  not  await  developments,  but  aspirate  to  ascertain  the  nature 
of  the  fluid,  and,  if  you  discover  pus,  operate  forthwith. 

There  are  two  leading  t^^Des  of  empyema — leading  types  as  regards 
their  bearing  on  the  nature  of  the  operation — acute  and  chronic  em- 
pyemata;  and  their  treatment  often  is  radically  difficult.  Take  pneu- 
mococcus empyema  as  an  example  of  acute  empyema:  empt}'  the  sac 
and  establish  drainage  in  a  simple  manner;  employ  general  anesthesia, 
as  a  rule;  ether  carefully  given  by  an  expert,  with  the  patient  in  a 
sitting  position,  is  no  more  dangerous  to  the  lung  than  chloroform,  and 
is  less  likely  to  depress  the  heart.  If  the  empyema  is  on  the  left,  and 
if  the  heart  is  greatly  dislocated,  it  is  wise  often  to  aspirate  off  the  pus, 
a  part  at  a  time,  lest  sudden  relief  of  pressure  dislocate  a  possible  cardiac 
thrombus,  and  kill  the  patient — an   accident  by  no  means  unknown. 

*  The  term  "empyema  "  is  usually  applied  to  a  collection  of  pus  in  the  pleural 
cavity,  though  we  use  it  also  to  denote  similar  collections  in  the  gall-bladder,  the 
antrum  of  Highmore,  etc. 


PYOTHORAX 


491 


Ordinarily,  however,  such  preliminary  aspiration  is  needless.  Cut 
down  upon  the  seventh  or  eighth  rib,  in  the  axillary,  anterior  axillary, 
or  posterior  axillary  line,  using  either  a  transverse  or  a  longitudinal  in- 
cision; free  the  rib  for  about  four  inches;  dissect  off  the  periosteum 
with  a  blunt  instrument;  open  and  drain  the  pleural  cavity,  and  insert  a 
rubber  tube — the  best  of  which,  for  this  purpose,  is  Henry's  rubber 
drainage-tube  or  bobbin,  which  is  self-retaining,  and  does  not  protrude 
either  into  the  cavity  or  beyond  the  skin.  Another  admirable  method  of 
securing  drainage  is  to  stitch  the  parietal  pleura  to  the  skin.  The  opening 
must  be  lightly  tamponed  to  prevent  too  early  glueing  up.    It  is  not  wise 


Fig.  312. — Resection  of  ribs  (after  Brewer  in  Keen's  Surgery). 


to  wash  out  the  cavity  unless  too  abundant  coagula  are  present.  In  such 
case  usually  one  may  wipe  them  out  or  gently  irrigate  the  cavity  before 
inserting  the  tube.  Then  sew  up  the  skin-wound  about  the  drainage 
opening  and  apply  an  abundant  absorbent  dressing.  In  most  cases, 
if  all  goes  well,  especially  if  the  case  has  been  taken  early,  prompt  con- 
valescence will  ensue.  The  patient  should  be  encouraged  to  sit  up  as 
soon  as  he  is  strong  enough,  and  should  be  taught  graduated  breathing 
exercises  in  order  to  encourage  lung  expansion.^ 

^  See  p.  483  for  account  of  the  Sauerbruch  cabinet  and  its  advantages  in  the  ope- 
ration for  empyema  and  for  subsequent  drainage. 


492 


THE    CHEST 


I  have  recommended  excision  of  a  rib  for  drainage,  and  I  repeat  that 
recommendation ;  an  excision  is  preferable  to  mere  incision  and  drainage 
between  ribs.  The  operation  between  the  ribs  fails  to  provide  an  avenue 
for  proper  inspection  of  the  chest  and  for  long-continued  drainage. 

Be  sure  not  to  remove  a  rib  behind  so  high  up  that  the  scapula  may 
fall  over  it.  If  you  operate  through  the  back,  take  the  ninth  rib,  and 
not  the  eighth  or  seventh. 

In  some  cases  the  diaphragm  rises  as  high  as  the  fourth  or  fifth  inter- 
space, and  lies  close  against  the  chest-wall  behind.  Be  careful  not  to 
cut  through  the  diaphragm  in  opening  the  chest.  Most  surgeons  have 
been  caught  in  this  pitfall. 

The  treatment  of  chronic  empyema  is  a  different  matter  from  that 
of  acute  empyema,  but  if  all  acute  empyemas  were  operated  upon  prop- 


Fig.  313. — Osteoplastic  tlioracotomy  (after  Brewer  in  Keen's  Surgery). 


erly  and  promptly,  chronic  empyema  would  almost  cease  to  exist.  I 
beg  the  student  to  bear  in  mind  carefully  the  distinction  between  the 
two  conditions,  acute  and  chronic  empyema,  and  especially  the  distinc- 
tion between  methods  for  their  relief.  In  chronic  empyema  the  pleurse 
become  greatly  thickened,  so  that  those  membranes  assume  the  ap- 
pearance of  tough,  strong,  and  tenacious  envelops  incircling  the  pus- 
cavity,  lining  the  wall  of  the  chest,  and  covering  the  surface  of  the  lung 
corresponding  to  the  affected  area.  One  perceives,  immediately,  there- 
fore, that  mere  aspiration  or  simple  drainage  of  such  a  cavity  cannot 
bring  about  a  permanent  cure,  for  the  stiff  wall  of  the  cyst  cavity  re- 
mains after  drainage,  holds  the  lung  away  from  the  chest,  and  persists 
as  a  pus-secreting  membrane. 

How  shall  we  close  up  this  abnormal  cavity?     Three  methods  within 


PYOTHORAX 


493 


recent  years  have  come  into  vogue,  and  these  methods  or  their  modifi- 
cations often  result  successfully:  Estlander's  operation;  Schede's  opera- 
tion, and  Fowler's  operation,  sometimes  called  the  operation  of  Delorme. 
All  these  operations  are  dangerous,  and  increasingly  dangerous  in  the 
order  I  have  given.  In  cases  of  chronic  empyema  the  surgeon  is  dealing 
with  patients  weakened  by  long-standing  illness.  They  endure  badly 
capital  operations,  so  that  frequently  it  is  necessary  to  proceed  with 
these  maneuvers  in  detail.  I  have  operated  by  Schede's  method  on 
the  same  patient  seven  successive  times  before  curing  him.  In  a  word, 
Estlander's  operation  consists  in  removing  part  or  all  of  the  ribs  over 
the  affected  area,  which  may  mean  all  the  ribs  on  one  side,  from  the 
second  to  the  ninth  inclusive.  This  allows  the  chest-wall  to  fall  in  and 
the  parietal  pleura  to  become  adherent  to  the  visceral  pleura.     Various 


Fig.  314. — Bryant's  operation  (after  Brewer  in  Keen's  Surgery). 


incisions  are  employed  by  various  operators — the  T-incision;  the  L-inci- 
sion;  the  U -incision.  The  U -incision  is  the  one  I  prefer  as  I  picture  it  in 
Fig.  314.  Turn  up  a  great  flap  of  the  soft  parts,  expose  the  ribs,  cut  up 
each  rib  to  be  excised  and  break  it  away  with  the  periosteum  in  either 
direction.  Posteriorly  it  breaks  off  at  the  angle,  and  anteriorly,  at  the 
costal  cartilage.  In  many  cases  it  may  be  advisable  to  cut  the  ribs  away 
carefully  over  a  given  area.  After  removing  the  ribs,  replace  and  sew  up 
the  soft  parts  and  provide  adequate  dependent  drainage.  Convalescence 
is  slow,  and  resulting  deformity  is  the  rule,  but  a  fairly  competent,  useful 
lung  is  sometimes  obtained.  After  this  operation,  as  after  all  other  opera- 
tions for  chronic  empyema,  the  patient  should  be  encouraged  to  lead  an 
out-of-doors  life  and  practise  pulmonary  gymnastics — walking  and  hiU- 
climbing,  having  due  regard  always  to  the  condition   of  his  heart. 


494  THE   CHEST 

Schede's  operation  is  a  modification  of  Estlander's.  Not  content  with 
removing  the  ribs,  Schede  supplements  that  procedure  by  excising  all  the 
thickened  parietal  pleura  with  the  ribs  and  periosteum.  As  a  result,  the 
soft  parts  of  the  chest  fall  in  at  once  upon  and  become  adherent  to  the  vis- 
ceral pleura.  Fowler's  operation,  in  turn,  is  an  extension  of  the  principle 
of  Schede's  operation,'  Not  content  with  removing  the  parietal  pleura, 
he  extends  the  peeling-off  process  and  removes  all  the  thickened  mem- 
brane from  chest-wall,  lung,  and  diaphragm,  leaving  a  raw  surface  and 
a  freed  lung,  which  should  now  be  able  to  expand  and  fill  the  cavity. 
The  subsequent  treatment  consists  in  restoring  the  flap  of  soft  parts  and 
draining  the  w'ound.  The  question  which  confronts  every  surgeon  when 
he  approaches  a  given  case  is  what  operation  shall  he  do,  and  how  far 
shall  he  carry  his  dissection.  One  cannot  lay  down  any  rule  which  shall 
meet  all  conditions,  but  in  general  terms  it  is  fair  to  say  that  the  extent 
of  the  operation  will  depend  upon  the  chronicity  of  the  case,  the  amount 
of  pleura  involved,  and,  most  of  all,  upon  the  condition  of  the  patient. 
Usually  one  hopes  to  succeed  by  performing  Estlander's  operation,  and 
if  that  fails  to  cure,  one  expects  to  follow  it  up  with  more  extensive 
dissections  after  the  manner  of  Schede  or  Fowler.  I  cannot  but  regard 
Fowler's  operation  as  extremely  severe,  to  be  approached  with  hesita- 
tion and  as  a  last  resort.-  There  has  been  more  or  less  confusion  in 
the  minds  of  surgeons  as  to  the  extent  of  rib  resection  which  should  be 
done  in  following  Fowler's  technic.  As  a  rule,  one  need  resect  enough 
ribs  only  to  allow  of  free  manipulation  and  dissection  within  the  chest 
cavity,  but  in  certain  cases  it  seems  necessary  to  make  a  much  wider 
resection  of  ribs,  as  is  done  in  the  Estlander  operation. 

After  all  is  said  regarding  these  various  radical  operations  for  chronic 
empyema,  we  cannot  often  look  for  a  perfect  outcome.  The  mortality 
is  high ;  failure  to  cure  completely  is  frequent,  and  those  persons  even 
who  are  reported  cured  must  expect  to  go  through  life  with  seriously 
crippled  lungs  and  a  depressed  vitalit}'.  The  corollary  to  all  this  has 
been  often  repeated — acute  empyema  should  be  operated  upon  earh', 
and  not  allowed  to  progress  to  the  chronic  stage. 

Hydrothorax  develops  in  the  course  of  some  general  circulatory  dis- 
turbance, and  is  of  the  same  nature  as  abdominal  ascites.  If  the  chest 
become  so  full  of  fluid  that  the  lungs  and  heart  labor  in  action,  it  may 
be  necessarv'  to  perform  aspiration.  Othei-wise  the  primar}'  disease  alone 
should  be  treated. 

^  George  Ryerson  Fowler,  in  New  York  Med.  Rec,  December  30,  1893,  published 
his  first  reports  of  this  operation.  About  this  same  time  Delorme  was  working  at 
the  problem  with  conclusions  similar  to  Prowler's.  Although  Delorme  presented  to 
the  French  Surgical  C'ongre.ss,  in  April,  1893,  the  results  of  his  experiments  in  the 
cadaver,  he  did  not  do  his  first  on  a  living  patient  until  some  months  after  Fowler 
had  done  so,  and  Fowler's  early  work  was  done  without  a  knowledge  of  Delorme's 
experiments. 

2  Kurpjuweit,  Beit.  z.  klin.  Chir.,  vol.  xxxiii,  p.  627,  has  published  statistical 
results  showing  that  Fowler's  operation,  known  as  decortication  of  the  lung,  has 
given  a  percentage  of  35.7  complete  recoveries:  19.7  improved;  33.9  unimproved,  and 
a  mortality  of  10.7.  Estlander's  operation,  on  the  other  hand,  shows  a  percentage 
of  56.3  cured;  20  per  cent,  improved;  3  per  cent,  unimproved,  and  a  mortahtj-  of 
20  per  cent. 


PYOTHORAX  495 

Hemothorax  is  a  subject  I  have  ah-eady  mentioned  in  connection 
with  surgery  of  the  lung.  It  is  produced  by  penetrating  wounds,  the 
crushing  of  ribs,  or  the  pathologic  erosions  of  vessels  in  the  chest-wall 
(aneurysm,  tuberculosis,  etc.).  1  have  already  indicated  the  treatment, 
which  is  symptomatic  generally — rest  and  bandaging,  though  rarely, 
when  the  symptoms  are  alarming,  the  surgeon  may  be  obliged  to  open 
the  thorax  and  ligate  or  tampon  the  bleeding  vessel. 

Chylo thorax  deserves  little  mention,  for  it  is  a  rare  condition.  It 
results  from  an  injury  to  the  thoracic  duct  which  produces  an  escape  of 
chyle  into  the  pleural  cavity.  A  positive  diagnosis  can  be  made  by  an 
examination  of  the  aspirated  fluicl,  which  is  cream  like,  of  low  specific 
gravity,  and  contains  sugar,  lymphocytes,  and  minute  fat-drops.  No 
active  treatment  is  practicable.  Most  patients  recover  under  rest  and 
bandaging. 

Tumors  of  the  pleura  attracted  some  little  attention  a  few  years 
ago,  for  they  were  brought  to  our  notice  by  such  interesting  writers  as  E. 
Wagner,  Schulz,  Frankel,  Lenhartz,  and  Lochet,  but  in  practice  such 
tumors  rarely  are  seen.  Especial  attention  has  been  called  to  a  peculiar 
primary  tumor  of  the  pleura,  an  endothelioma  which  presents  a  dif- 
fuse pleura]  thickening,  suggesting  ordinary  fibrous  thickening.  The 
microscope  shows  an  extensive  endothelial  growth.  The  lung  becomes 
compressed;  there  is  dulness  over  the  affected  area,  and  the  aspirating 
needle  draws  a  chocolate-colored  fluid  containing  characteristic  nests 
and  cells.  Rare  as  are  privmry  malignant  growths  in  the  pleura, 
secondary  cancer  and  sarcoma  are  common  enough,  and  are  the  result 
of  malignant  disease  in  neighboring  parts,  especially  in  the  breast. 
Malignant  involvement  of  the  pleura  nearly  always  produces  effusion, 
which  is  serous  or  bloody  or  beclouded  with  detritus. 

In  the  case  of  primary  endotheliomata  operative  treatment  is  of 
little  value.  We  can  do  nothing  but  palliate  the  symptoms.  As  for 
secondary  growths,  it  may  rarely  seem  wise  to  resect  extensively  the 
chest-wall,  but,  as  a  rule,  we  can  do  no  more  than  relieve  pressure  by 
aspiration  and  give  morphin.  In  case  a  resection  of  the  chest-wall 
be  undertaken,  one  should  employ  a  differential  pressure  apparatus  to 
inflate  the  lung. 

Echinococcus  of  the  pleura  is  rare.  I  have  already  discussed  this 
subject  under  the  caption  Echinococcus  of  the  Lung. 


CHAPTER  XVIII 

THE  HEART  AND  PERICARDIUM 

Fifteen  years  ago  the  heart  had  not  been  brought  within  the  sur- 
geon's field,  and  wounds  of  the  heart  especially  were  held  to  be  beyond 
surgical  treatment.  Dennis/  writing  in  1S95,  says:  "  The  treatment  of 
wountls  of  the  heart  consists  in  lowering  the  head  to  prevent  cerebral 
anemia,  the  administration  of  opium  to  relieve  pain  and  to  control  the 
inflammation,  and  the  application  of  artificial  warmth  to  the  surface  of 
the  body";  but  in  the  very  next  year,  1S96,  Farina  reported  the  first 
recorded  case  of  suture  of  the  heart-wall  for  a  penetrating  wound. 
Farina's  patient  died  of  pneumonia  on  the  fifth  day,  but  that  surgeon's 
operation  seems  to  have  been  successful  in  repairing  the  damage  to  the 
heart.  Operations  on  the  pericardium  antedated  operations  on  the 
heart  by  nearly  a  century,  and  we  read  in  the  memoir  of  Baron  Larrey 
how  that  distinguished  French  surgeon  aspirated  the  pericardial  sac 
in  1798.  We  see,  therefore,  that  the  surgery  of  the  pericardium  seemed 
possible  to  the  older  surgeons,  and  w-e  find  surgical  literature  dealing 
frequently  with  the  subject. 

The  heart  and  pericardium  form  a  portion  of  the  circulatory  appar- 
atus, and  many  writers  discuss  their  diseases  in  connection  with  the 
broader  subject  of  circulatory  disturbances.  It  seems  more  suitable  to 
me,  however,  to  treat  of  the  heart  and  pericardium  from  the  anatomic 
rather  than  from  the  physiologic  viewpoint — to  group  the  diseases  of 
these  organs  with  diseases  of  the  chest,  rather  than  with  diseases  of  the 
blood-vessels,  because  clinically  the  surgeon  deals  with  the  heart  and 
pericardium  as  isolated  organs.  There  are  two  main  divisions  of  the 
surgery  of  these  structures:  operations  for  fluid  in  the  pericardium, 
including  adhesions  between  the  layers  of  that  membrane;  and  opera- 
tions for  repair  of  penetrating  heart  wounds. 

The  popular  notion  that  wounds  of  the  heart  are  necessarily  and 
instantly  fatal  is  erroneous.  Surgical  writers  from  Pare  to  men  of 
our  own  time  relate  cases  of  persons  surviving  such  wounds  for  a  longer 
or  shorter  period.  Indeed,  G.  P'ischer,  in  1S67,  estimated,  from  a  study 
of  452  cases  of  wounds  of  the  heart,  that  from  7  to  10  per  cent,  of  per- 
sons so  injured  recovered  completely.  The  fact  is  known  to  all  physi- 
cians that  pathologic  heart  ruptures  may  be  survived  for  a  time.  I  my- 
self had  under  my  care  a  man  of  fifty  who  survived  a  cardiac  rupture 
for  nine  days.  Degeneration  of  the  heart  muscle  renders  futile  repair 
of  pathologic  rents.  Aspiration  of  the  right  auricle  has  been  done 
to  relieve  the  engorged  heart  in  cases  of  acute  pulmonary  congestion, 
1  Dennis'  System  of  Surgerj',  vol.  iii,  p.  218. 
496 


OPERATIONS    UPON  THE    PERICARDIUM  497 

though  the  operation  is  desperate  and  rarely  effective.  Collections  of 
fluid,  from  their  pressure  within  the  pericardium,  may  embarrass  seri- 
ously or  check  the  heart's  action. 

PERICARDIAL  EFFUSIONS 

The  simpler  forms  of  pericardial  effusion  may  be  dealt  with  by 
aspiration  or  incision.  In  such  cases  aspiration  is  comparatively  easy 
and  safe,  because  the  heart  is  crowded  back  into  the  depths  of  the  peri- 
cardium. Aspiration  is  not  safe,  however,  in  cases  of  purulerit  effusion 
into  the  pericardium,  because  then  the  heart's  apex  may  be  held  forward 
to  the  anterior  chest-wall  by  adhesions. 

In  recent  years  the  possibilities  of  heart  surgery  or  direct  operative 
dealing  with  the  heart  have  been  made  to  appear  as  important  future 
possibilities.  George  W.  Crile,  in  1903  and  1904,  published  an  extremely 
interesting  series  of  experiments  and  operations  on  the  heart,  showing 
that  after  apparent  death  in  dogs  and  in  man,  even  when  half  an  hour 
of  suspended  animation  has  elapsed,  the  heart  may  be  stimulated  to 
resume  its  functions  by  direct  rhythmic  pressure  over  the  pericardium, 
or  by  subdiaphragmatic  massage, — the  abdomen  being  opened  for  the 
purpose, — supplemented  by  artificial  respiration  and  long-continued 
infusion  of  1 :  50,000  adrenalin  chlorid  solution.  Harvey  Gushing, 
working  in  the  Hunterian  Laboratory  of  the  Johns  Hopkins  University, 
has  demonstrated  the  possibility  of  producing  artificial  cardiac  lesions  by 
intraventricular  incisions  of  the  cardiac  valves,  with  a  resulting  recov-' 
ery  from  the  operation  except  for  the  cardiac  lesion.  This  extremely 
interesting  work  suggests  the  possibility  of  intracardiac  manipulations 
for  the  relief  of  valvular  stenoses.  Theoretic  as  these  considerations 
may  be,  the  work  of  such  experimenters  has  proved  conclusively  that 
the  heart  may  be  approached  and  handled  with  boldness;  at  the  same 
time  the  practical  experience  of  many  surgeons  has  shown  the  reason- 
ableness and  importance  of  operating  upon  the  heart  and  pericardium 
for  traumatic  lesions  of  these  structures.  In  all  this  we  are  considering 
a  strikingly  interesting  and  Httle  explored  field  for  surgery. 

OPERATIONS  UPON  THE  PERICARDIUM 

Injuries  to  the  pericardium  may  require  the  surgeon's  intervention. 
They  occur  from  crushing  blows  which  fracture  ribs  and  tear  the  peri- 
carclium,  and  they  are  due  to  penetrating  wounds  also — gunshots  and 
stabs.  Pericarditis  may  give  rise  to  serous,  purulent,  and  hemorrhagic 
effusions.  Good  practice  in  these  days  limits  puncture  of  the  pericar- 
dium to  aspiration  for  the  purpose  of  diagnosis.  If  fluid  is  to  be  evac- 
uated properly,  the  pericardium  should  be  opened  with  a  knife.  Com- 
monly, the  best  place  for  puncture  is  in  the  sixth  intercostal  space,  close 
to  the  edge  of  the  sternum,  for  at  this  point  there  is  the  least  danger  of 
wounding  the  heart  or  the  pleura. 

Surgeons  are  not  agreed  as  to  the  best  method  for  incising  the  peri- 

32 


498 


THE    f'HEST 


canlium  (poricanliotomy).  Some  suifioons  have  advocated  making  a 
large  costocartilaginous  flap  by  cutting  through  the  fourth,  fifth,  and 
sixth  costal  cartilages,  and  thus  exposing  a  large  opening.  For  many 
reasons  this  method  is  admirable,  but  there  are  the  objections  that  it 
consumes  much  time  and  often  involves  wounding  the  j^leura.  This 
last  objection  may  not  be  of  serious  consequence  if  the  pleura  has  been 
damaged  already  by  the  violence  \vhich  necessitated  the  operation. 
Mv  own  dissections  of  the  cadaver  have  convinced  me  that  Kocher's 


m 


Fig.  315. — Kocher's  approach  to  the  pericardium. 


method  of  approaching  the  pericardium  is.  valuable.  He  makes  a  rec- 
tangular incision,  one  limb  nmning  down  the  middle  of  the  sternum, 
the  other  outward  along  the  sixth  costal  cartilage  and  rib.  He  turn? 
up  a  flap  of  soft  parts  with  the  perichondrium  of  the  cartilage  and  the 
periosteum  of  the  sternum.  He  then  divides  the  sixth  costal  cartilage, 
and  pulls  the  sixth  rib  upward.  If  he  looks  for  a  greater  exposure, 
he  divides  the  fifth  and  fourth  cartilages  also.  Then  the  intercostal 
muscles  are  stripped  off  and  the  internal  mammary  vessels  are  exposed. 


WOUNDS    OF   THE    HEART  499 

One  now  perceives  at  the  bottom  of  the  wound  the  tough,  glistening 
pericardium,  which  may  be  demonstrated  more  thoroughly  by  pushing 
aside  with  the  finger  the  edge  of  the  pleura  (to  be  distinguished  by  the 
pad  of  fat  covering  it),  together  with  the  intercostal  muscle  and  the 
internal  mammary  artery. 

If  the  pericardium  contain  a  non-purulent  fluid,  it  is  best  treated 
by  opening  it  low  down  along  the  edge  of  the  sternum,  drawing  off  the 
fluid,  and  sewing  up  without  drainage  the  wound  in  the  pericardium. 
The  chest-flap  is  then  replaced  and  repaired,  with  superficial  drainage, 
to  provide  for  the  possibility  of  an  intrathoracic  infection. 

Should  the  surgeon  find  a.  pyopei-icardium^  present,  he  must  drain  the 
pericardial  sac — preferably  wath  a  cigaret  wick. 

Adhesions  between  the  heart  and  parietal  pericardium  or  chest- 
wall  are  due  to  pericarditis  or  traumatism,  and  cause  distressing  symp- 
toms—pain, dyspnea,  and  palpitation.  The  surgeon  treats  this  con^ 
dition  by  separating  the  adhesions  (cardiolysis)  or  by  cutting  costal 
cartilages  so  as  to  allow  the  chest-wall  to  sink  in  and  relieve  the  tension 
of  the  adhesions.  The  former  operation,  cardiolysis,  must  be  performed 
carefully,  and  its  completion  must  be  abandoned  if  there  appears  to  be 
danger  of  tearing  the  heart.  Section  of  cartilages  is  an  operation  rela- 
tively safe,  and  often  satisfactory  in  its  results. 

WOUNDS  OF  THE  HEART 

Operations  upon  the  heart  have  been  confined  hitherto  to  the  repair 
of  heart  wounds,  and  there  is  the  suggested  paracentesis  auriculi,  which 
is  shunned  by  the  wise.  Heart  wounds  cause  instant  and  alarming 
s3anptoms :  pain;  hemorrhage,  often  copious,  sometimes  slight;  pal- 
pitation; dyspnea;  syncope.  The  symptoms  depend  on  the  site  and 
extent  of  the  heart  wound.  Death  is  instantaneous  if  the  ventricle  is 
torn  widely  open  or  the  center  for  heart-block  is  damaged,  or  the 
auricles  injured.  Fortunately,  the  ventricles  are  the  parts  commonly 
injured — the  left  ventricle  much  more  often  than  the  right .^  A  bullet 
or  knife  may  wound  the  heart-wall  without  perforating  the  ventricle. 
This  superficial  wound  may  bleed  profusely  and  confuse  the  diagnosis. 
A  perforating  wound,  if  small,  may  bleed  but  little,  owing  to  its  being 
closed  with  every  systole  by  the  interlocking  of  the  heart's  muscles. 
Often  there  is  but  little  external  bleeding.  An  important  complication 
of  these  wounds  is  coincident  damage  to  the  lungs  and  pleura,  resulting 
variously  in  pneumothorax,  hemothorax,  or  pulmonary  atelectasis  even. 

The  surgeon  must  take  note  especially  of  those  victims  of  heart 
wound  who  do  not  die  at  once.  Such  are  they  in  whom  operative  re- 
pair of  the  cardiac  wound  is  imperative.  The  patient  is  seen  in  collapse, 
gasping,  with  cold  extremities,  cyanotic;  the  pulse  is  soft  and  rapid; 
the  heart-sounds  are  muffled.  Frequently  there  is  hemorrhage  from  the 
heart  into  the  pericardium,  with  a  consequent  throttling  of  the  heart's 

1  Ellsworth  Eliot,  Jr.,  Suppurative  Pericarditis,  Ann.  Surg.,  January,  1909. 

2  L.  L.  Hill,  Wounds  of  the  Heart,  Med.  Rec,  September  19,  1908. 


500 


THE   CHEST 


action.  If  the  homorrhao;e  continues,  the  heart  will  be  brought  to  a 
standstill.  Our  one  and  obvious  expedient  is  to  relieve  the  ]:)ressure  by 
emptying  the  pericardium,  and  to  check  the  hemorrhage  by  sewing  up 
the  wound  in  the  heart. 

The  treatment  I  have  outlined  should  be  supi)lemented  by  proper 
stimulation — hot  bottles  and  blankets,  raising  the  foot  of  the  betl,  a 
hypotlermic  injection  of  morphin  and  atropin,  the  intravenous  injection 
of  a  pint  or  more  of  normal  saline  solution,  with  adrenalin  (1  :  50,000), 
and  the  application  of  Crile's  pneumatic  suit,  if  it  is  at  hand.  An  anes- 
thetic rarely  is  desirable,  and  if  any  is  given,  ether  only  is  permis- 
sible. 


Fig.  .316. — Vaughan's  case  of  heart  suturing  (redrawn  from  sketch):  1,  Heart:  2, 
deep  sutures;  .3,  superficial  sutures:  4,  pericardium:  o,  left  pleural  space:  6,  flap  of 
chest-wall,  including  fourth,  fifth,  and  sixth  ribs;  7,  outhne  of  heart. 


The  steps  of  the  operation  in  detail  are  these:  With  the  patient  in  a 
modified  Trendelenburg  position,  clean  up  rapidly  the  skin;  enlarge  the 
external  wound,  and  ascertain  the  condition  of  the  underlying  cartilages 
and  ribs.  If  they  are  found  divided,  advance  through  the  opening  thus 
provided.  If  they  are  intact,  turn  back  a  rib  in  the  fashion  I  have  al- 
ready described.  Seek  and  tampon  any  rent  in  the  pleura.  Expose 
the  pericardium  and  find  the  wound  in  that  membrane;  enlarge  the  peri- 
cardial wound ;  empty  the  pericardium  of  blood  and  clots,  and  look  for 
the  wound  in  the  heart.  One  may  find  great  difficulty  in  discovering 
this  heart  wound.      Gibbon^  reports  an  interesting  and  successful  case, 

1  John  H.  Gibbon,  Jour.  Amer.  Med.  Assoc,  February  10,  1906. 


WOUNDS   OF   THE   HEART  501 

in  which,  being  unable  at  once  to  discover  the  lesion  by  sight  or  touch, 
he  passed  his  fingers  behind  the  heart,  Hfted  it  forward  to  the  peri- 
cardial opening,  and  so  disclosed  the  heart  wound,  which  was  partly 
filled  with  a  clot,  and  was  situated  in  the  right  ventricle,  near  the  auricu- 
lovcntricidar  groove. 

Having  found  the  wound,  the  surgeon  will  make  easier  the  sewing 
it  up,  by  passing  first  two  deep  stay-sutures,  one  into  either  edge  of  the 
wound,  and  so  holding  forward  the  heart.  Use  round-pointed  intestinal 
needles.  Sew  up  the  wound  with  a  continuous  silk  or  catgut  suture, 
tie  it  during  diastole,  and  avoid  entering  the  endocardium.  Then  drop 
back  the  heart,  sponge  out  the  pericardial  sac,  and  sew  it  up  after 
providing  drainage.  Some  surgeons  protest  that  drainage  is  not  neces- 
sary and  that  it  promotes  suppuration;  but  in  view  of  the  possibility 
of  further  leakage  from  the  heart-wall  and  of  the  collecting  of  blood, 
serum,  or  pus  in  the  pericardium,  I  cannot  convince  myself  that  it  is 
safe  to  leave  the  sac  undrained.  Complete  the  closure  of  the  wound  by 
treating  properly  any  rent  in  the  pleura;  drain  it,  if  a  rent  exists.  Re- 
place the  cartilage  and  skin -flap,  and  drain  the  superficial  wound  also. 
Apply  a  large  absorbent  dressing  with  a  firm  swathe,  and  put  the  patient 
quickly  into  a  warm  bed.  If  the  patient  lives,  the  surgeon  will  have  an 
anxious  time  for  a  week  or  more.  There  are  the  dangers  of  recurring 
hemorrhage,  of  incomplete  drainage,  of  cardiac  collapse,  of  infection, 
of  pneumonia,  and  of  empyema.  The  first  dressing  should  be  done  after 
twenty-four  hours,  and  after  that  the  various  complications  must  be 
met  and  combated  as  they  arise. 

We  are  coming  to  see  that  wounds  of  violence  to  the  heart  offer 
brilliant  opportunities  for  the  surgeon.  Without  operation  90  per 
cent,  of  the  victims  die;  with  operation,  64  per  cent.,  and  the  mortality 
is  falling.  All  surgeons  are  impressed  with  the  importance  of  prompt 
repair  for  penetrating  wounds,  for  stab-wounds  especially,  as  they  are 
least  likely  to  involve  the  ventricular  septum.  Shot-wounds  are  more 
fatal,  for  they  penetrate  deeper  than  stab-wounds,  but  shot-wounds 
even  may  sometimes  be  repaired.  Too  little  regard  has  been  paid  to 
the  after-effects  of  crushing  wounds  which  fracture  the  costal  cage  and 
tear  the  pericardium.  From  such  damage  patients  may  recover,  but 
later  develop  cardiac  adhesions,  with  dilatation  and  symptoms  of 
insufficiency.  In  several  such  reported  cases  cardiolysis,  or,  better, 
section  of  the  overlying  chest-wall,  has  given  marked  relief  to  the 
symptoms. 

It  may  still  be  proper  to  feel  that  the  whole  subject  of  heart  surgery 
is  sub  judice,  but  there  can  be  no  doubt  that  it  offers  a  widening  and  im- 
portant field  for  surgical  endeavor. 


CHAPTER  XIX 

THE  CHEST-WALL— THE  BREAST 

The  Chest-wall 

In  the  three  preceding  chapters  we  have  been  discussing  diseases  and 
injuries  of  the  thoracic  viscera — the  bronchi,  lungs,  pleura,  and  heart. 
In  this  chapter  we  shall  deal  with  lesions  of  the  thoracic  cage  and  its 
coverings.  In  general  terms,  the  important  external  lesions  of  the 
thorax  may  be  grouped  under  inflammations,  wounds,  and  tumors; 
while  far  the  most  interesting  of  the  special  conditions  in  this  relation 
for  surgeons  are  penetrating  wounds  of  the  chest  and  breast  tumors. 
To  breast  tumors  especially  surgeons  in  civil  practice  have  turned  their 
attention  for  generations,  and  the  accumulated  literature  of  the  subject 
during  the  past  one  hundred  years  is  enormous.  We  are  now  dealing 
with  diseases  on  the  surface  of  the  body,  diseases  obvious  to  touch  and 
sight;  and  we  may  well  imagine  how  such  disorders  in  all  time  must  have 
attracted  the  intelligent  interest  of  mankind.  In  like  manner  wounds 
of  the  chest-wall  have  always  been  objects  of  surgical  activity,  and  mil- 
itary surgeons  especially  have  dealt  with  them  familiarly.  We  shall 
not  discuss  bone  fractures  in  this  chapter,  but  reserve  that  subject 
for  special  consideration  in  the  chapter  on  Fractures. 

The  soft  parts  of  the  chest-wall  are  subject  to  such  various  contusions, 
wounds,  and  inflammations  as  are  found  in  other  parts  of  the  body,  but 
certain  of  these  lesions  when  found  upon  the  chest  have  their  own  char- 
acteristics. 

CONTUSIONS  OF  THE   CHEST 

Contusions  of  the  chest  may  be  supercficial  or  deep,  and  may  be  as- 
sociated or  not  with  damage  to  the  viscera.  In  any  case  the  pain  which 
is  experienced  is  increased  by  the  movements  of  costal  respiration. 
Skin-wounds  call  for  the  simple  treatment  which  I  shall  explain  in  the 
chapter  on  Minor  Surgery.  Wounds  of  the  muscles  and  ligaments  may 
cause  great  inconvenience,  while  damage  to  the  ribs  gives  rise  to  ex- 
cruciating pain. 

In  all  cases  of  thoracic  wounds,  therefore,  the  patient  experiences 
peculiar  symptoms — intermitting  pain,  increased  by  respiration;  a  fre- 
quent sense  of  suffocation;  a  feeling  of  collapse  and  prostation;  some- 
times dyspnea  and  palpitation.  He  is  most  comfortable  in  the  semi- 
prone  or  upright  positions,  and  involuntarily  he  employs  diaphragmatic 
breathing. 

An  unusual  but  frequently  quoted  result  of  severe  chest  contusion  is 
traumatic  asphyxia,  a  striking  case  of  which  condition  was  reported  by 
502 


PLATE    I. 


Traumatic  Asphyxia. 

Discoloration  following  forcible  compression  of  the  thorax   (Beach  and  Cobb,  in 

"Annals  of  Surgery,"    April,  1904). 


INFLAMMATIONS  503 

Beach  and  Cobb '  a  few  years  ago.  I  saw  the  case  at  the  time,  and 
was  impressed  by  the  extraordinary  appearance  of  the  man,  whose  pic- 
ture I  reproduce  (Phite  I).  Such  conditions  are  due  to  heavy  crushing 
forces  exerted  upon  the  thorax.  The  man  in  question  was  crushed  in  an 
elevator.  The  discoloration  of  the  skin  is  due  to  stasis  from  mechanical 
overdistention  of  the  veins  and  capillaries,  and  not  to  extravasation 
of  blood  into  the  tissues.  The  sharp  limitation  of  color  to  the  head  and 
neck  is  probalily  due  to  the  lack  of  valves  in  the  jugular  and  facial  veins. 
The  treatment  for  most  chest  injuries  not  involving  the  viscera 
consists  of  repair  of  the  soft  parts,  the  application  of  an  abundant 
absorbent  dressing,  and  fixation  of  the  chest  by  plaster  strapping, 
which  should  immobilize  the  ribs  on  the  side  affected,  and  should  extend 
well  over  on  to  the  opposite  side,  both  behind  and  before.  Cases  of 
traumatic  asphyxia  seem  to  be  little  benefited  by  treatment,  though 
writers  have  suggested  that  artificial  respiration  and  the  giving  of 
oxygen  might  be  of  value  immediately  after  the  accident.  In  the  case 
I  have  quoted,  and  in  other  similar  cases  which  have  recovered,  the 
patients  got  well  under  rest  in  bed  merely. 

INFLAMMATIONS 

Inflammations  of  the  thoracic  wall,  especially  suppurative  inflam- 
mations, may  involve  much  tissue,  for  the  chest  is  overlaid  by  a  series 
of  broad  flat  muscles,  between  the  planes  of  which  pus  burrows  rapidly. 
Great  abscesses  form  in  the  back  and  under  the  breast,  causing  severe 
constitutional  disturbance  and  great  local  distress.  Such  inflam- 
mations must  be  treated  promptly  by  opening  and  washing  out  and 
draining  the  abscess  cavities.  These  cases  of  localized  infection  are 
peculiarh'  suitable  for  opsonic  vaccination.  I  have  seen  prompt  and 
striking  improvement  follow  this  treatment. 

Burns  of  the  chest  occur  frequently  in  ci\dl  practice.  When  they 
are  at  all  extensive,  they  are  grave.  Indeed,  death  may  follow  apparently 
trivial  bums  of  the  chest.  These  lesions  call  instantly  for  careful  treat- 
ment. One  should  give  morphin  to  quiet  the  pain  and  diminish  shock, 
and  should  carefully  exclude  the  air  by  wrapping  in  oiled  compresses 
covered  with  heavy  absorbent  dressings. 

Boils  and  carbuncles  are  often  found  upon  the  chest,  especially 
in  the  thick  skin  of  the  back.  The  treatment  of  these  lesions  is  that 
treatment  of  boils  and  carbuncles  which  I  describe  in  the  chapter 
on  ilinor  Surgery  (Chapter  XXVI).  In  addition,  they  are  especially 
favorable  objects  for  opsonic  vaccinations. 

Tuberculous  sinuses  associated  wath  tuberculosis  of  the  ribs,  clavi- 
cles, sternum,  and  vertebrae  burrow  through  the  chest-wall  and  appear 
at  various  points  on  the  thorax.  Often  they  become  the  subjects  of 
prolonged  and  tedious  treatment.  The  sinuses  must  be  dissected  out 
carefuUy  and  the  underh'ing  tuberculous  focus  must  be  exposed  and 
removed.  There  results  generally  from  the  operation  a  large  open  wound, 
which  must  be  packed  carefidly  and  made  to  heal  from  the  bottom. 
1  H.  H.  A.  Beach  and  Farrar  Cobb,  Ann.  Surg.,  April,  1904. 


504  THE    CHEST 

Actinomycosis  of  the  chest-wall  is  not  uncommon,  while  rarely 
echinococcus  disease  is  seen.  The  surgeon  must  expose  thoroughly 
these  processes  and  remove  or  drain  them,  as  best  he  may,  under  the 
circumstances. 


NEURITIS  OF  THE  INTERCOSTAL  NERVES 

Neuritis  of  intercostal  nerves,  commonly  known  as  intercostal  neu- 
ralgia, is  a  frequent  affection,  and  its  sources  are  manifold.  Generally, 
it  is  associated  with  the  so-called  rheumatoid  condition,  but  it  may  be 
due  to  disease  of  the  nerves  themselves,  to  disease  of  the  cord,  to  disease 
of  the  spinal  column  causing  pressure,  to  the  pressure  of  tumors  directly 
upon  the  nerves,  or  to  disease  of  the  ribs.  These  several  etiologic  fac- 
tors must  be  investigated  and  the  primary  causes  must  be  treated. 

In  addition  to  such  traumatic  and  inflammatory  lesions  the  surgeon 
will  be  called  occasionally  to  treat  tumors. 

TUMORS   OF   THE   CHEST-WALL 

There  is  a  considerable  variety  of  such  tumors,  which  develop  some- 
times from  the  soft  parts,  sometimes  from  the  bones  or  periosteum. 
Moreover,  metastatic  tumors  from  growths  in  the  vicinity,  such  as  can- 
cer of  the  breast,  attack  the  chest-wall  frequently.  There  are  the  com- 
mon benign  tumors,  nei-i,  sebaceous  cysts,  ivejis,  dermoids,  keloids,  fatly 
tutnors,  Jibrotriata,  neuromata,  cavernous  hemangiomata,  lymphangio- 
mata,  enchondromata,  and  compound  tumors,  all  of  which  may  disturb  the 
patient  by  their  mere  presence,  by  their  size,  and  by  the  pain  which 
they  cause.  These  tumors  are  benign,  and  may  be  removed  with  the 
knife  or  cautery.  In  several  instances  I  have  removed  successfully 
nevi  and  angiomata  by  the  injection  into  them,  .subcutaneously.  of 
several  syringefuls  of  boiling  water  (Fig.  (369),  which  causes  a  local 
necrosis,  with  resulting  absolution  of  the  mass. 

Sarcoma  and  carcinoma,  primarj^  in  the  chest-wall,  occasionally 
have  been  reported.  Such  tumors  are  distinguished  from  benign  growths 
by  the  rapidity  of  their  development,  by  the  pain  they  cause,  by  the 
appearance  of  metastases,  and  by  the  development  of  cachexia  in  the 
patient.  They  are,  unfortunately,  fatal,  usually,  in  spite  of  the  most 
radical  treatment.  Frequently  they  attack  the  ribs,  and  they  may 
invade  the  pleura.  It  is  a  serious  matter  to  excise  them,  but  excision 
offers  practically  the  only  chance  of  cure.  If  the  operation  necessitate 
opening  the  pleural  cavity,  the  surgeon  should  employ  the  Sauerbruch 
cabinet  or  some  one  of  the  positive  pressure  apparatus,  to  maintain  a 
proper  expansion  of  the  lungs. 

It  is  needless  here  to  discuss  the  nature  and  treatment  of  penetrat- 
ing wounds  of  the  chest  involving  the  thoracic  viscera,  as  we  have  al- 
ready considered  this  subject  in  Chapters  XVI,  XVII,  and  XVIII. 
Such,  in  brief  outline,  are  the  diseases  and  lesions  located  upon  the 
thoracic  wall. 


AXATOMY  505 

THE  BREAST 

There  remains  for  our  consideration  the  subject  of  diseases  of  the 
breast.  The  breast  is  the  most  important  and  striking  landmark  upon 
the  chest — the  organ  pecuHarly  Hable  to  injury,  infection,  and  tumor 
growth,  especially  in  women,  closely  connected  with  the  generative 
function,  and  of  extreme  interest  to  the  surgeon. 

Diseases  of  the  breast  have  been  the  subject  of  intelligent  surgical 
interest  for  generations,  but  it  is  within  our  own  generation  only  that 
final  and  satisfactory  conclusions  regarding  the  pathology  of  this 
organ  have  been  reached.  After  Virchow  published  his  observations 
on  cellular  pathology  and  the  nature  of  tumors,  some  measure  of  order 
in  our  conception  of  mammary  diseases  began  to  establish  itself,  but 
even  to-day  all  men  are  not  in  accord  as  to  the  classification  of  certain 
breast  tumors,  and  so  lately  as  1905  J.  Collins  Warren  wrote,  "  In  no 
department  of  surgery  has  the  classification  of  the  diseases  of  an  organ 
or  the  pathologic  nomenclature  been  more  confusing  than  in  the  case  of 
the  diseases  of  the  mammary  gland."  Most  physicians,  when  they  think 
of  disease  of  the  breast,  think  especially  of  the  two  most  common  lesions 
— cancer  and  abscess.  There  are  numerous  other  lesions  which  we  must 
consider  in  their  order.  Let  us  first,  however,  study  the  most  common 
disease,  cancer,  and  sundry  less  malignant  breast  tumors  with  which 
cancer  may  be  confused. 

A  few  words  first  on  the  subject  of  the  anatomy  and  development  of 
the  breast  must  detain  us,  for  without  a  clear  understanding  of  these 
matters  the  reader  cannot  proceed  intelligently. 

ANATOMY 

The  breast  in  women — we  need  not  consider  here  the  rare  breast 
diseases  in  men — extends  normally  from  the  third  to  the  sixth  or  seventh 
rib,  and  from  the  margin  of  the  sternum  to  the  anterior  axillary  line. 
It  covers  most  of  the  pectoralis  major  muscle,  and  is  easily  movable 
on  the  fascia  of  this  muscle.  Its  15  to  20  milk-ducts  terminate  by  fine 
openings  in  the  nipple.  The  areola  contains  sweat-glands  and  sebaceous 
glands,  which  may  become  cystic  or  inflamed.  Numerous  smooth 
muscle-fibers  run  down  from  the  nipple  and  areola  into  the  substance 
of  the  breast,  and  their  stimulation  causes  an  erection  of  the  nipple. 
These  fibers  must  not  be  confused  with  the  fibrous  processes  which  radi- 
ate from  the  skin  of  the  breast  down  between  the  lobules  of  the  gland. ^ 
Various  diseases  of  the  breast  may  affect  the  muscles  of  the  nipple  and 
cause  the  nipple's  retraction.  Cancer  of  the  breast  may  affect  the  fibrous 
processes  of  the  skin,  causing  them  to  shorten,  with  the  effect  that  the 
overlying  integument  appears  pitted,  with  many  minute  dimples.  At 
different  periods  of  life  the  breast  changes  in  size  and  in  its  histologic 
characteristics.  At  birth  the  gland  is  represented  by  a  series  of  radiating 
ducts  lined  with  an  epithehum  which  is  often  in  a  state  of  active  prolifer- 

1  The  suspensorj^  ligaments  of  Astley  Cooper. 


506  THE   CHEST 

ation,  causing  swelling  and  tonderness  of  the  babj-'s  breast  and  a  deposit 
of  broken-down  fat  and  epithelial  cells,  which  may  be  squeezed  in  a  milk- 
like  fluid  from  the  nipi:)le.  This  is  the  so-called  acute  mastitis  of  infants. 
From  infancy  until  puberty  the  breast  is  quiescent.  Then  comes  the 
hypertrophy  of  puberty,  when  there  appear  acini  lined  with  epithelium 
and  a  chdracteri.siic  nnjxo)natous  connective  tis.suc,  which  develops  about 
the  terminal  ducts  and  the  acini.  Note  must  be  made  of  this  peculiar 
connective  tissue,  which  was  first  described  by  Billroth,  for  it  is  the  site 
of  important  new-growths,  usually  benign.  This  is  that  periductal 
connective  tissue,  for  the  tumors  of  which  ^^'arren^  has  suggested  an 
important  modified  nomenclature. 

With  pregnancy  another  notable  change  takes  place  in  the  breast. 
The  epithelial  activity  of  the  gland  is  then  great,  the  acini  multiply,  and, 
as  Warren  remarks,  the  tree  may  be  said  to  be  in  full  leaf.  The  peri- 
ductal tissue  becomes  stretched  and  less  prominent.  After  lactation 
many  of  the  acini  disappear,  the  periductal  tissue  becomes  relaxed,  and 
the  breast  pendulous.  The  final  period  in  the  life-history  of  the  bi-east 
begins  in  middle  age.  The  gland  slowly  dries  up,  with  obvious  changes, 
noticeable  both  in  the  acini  and  in  the  periductal  tissue.  The  epithelium 
no  longer  proliferates,  but  degenerates.  Ducts  become  choked  with 
epithelial  debris  or  compressed  by  the  contracting  interstitial  tissue, 
and  blood-vessels  become  thrombosed  and  disappear.  These  changes 
are  not  uniform,  but  occur  in  scattered  islands  throughout  the  breast, 
so  that  the  gland  takes  on  the  familiar  "  cobble-stone"  feel.  With 
advancing  age  these  degenerative  changes  continue,  so  that  in  old  women 
the  mammary  gland,  much  as  in  infancy,  is  represented  by  a  few  ducts 
mereh^,  near  the  nipple,  and  small  bands  of  fibrous  stroma  infiltrated 
with  fat. 

The  breast  receives  its  blood-supply  from  the  axillary  and  internal 
manmiary  arteries  and  from  certain  branches  of  the  intercostal  arteries, 
and  its  nerve-supply  from  filaments  of  the  syinpathetic,  the  brachial  and 
cervical  plexuses,  and  the  intercostal  nerves.  The  lymphatic  connec- 
tions of  the  breast  are  far  more  important  than  the  blood  and  nerve 
connections.  The  lymph-vessels  and  nodes  of  the  breast  are  numerous. 
They  are  superficial  and  deep.  Some  lymphatics  belong  to  the  skin,  and 
are  found  especially  about  the  nipple,  whence  they  penetrate  within  the 
structure  of  the  gland  itself.  All  the  lymphatics  of  the  breast  join  at  the 
inferior  external  margin  of  the  gland  in  two  or  three  large  trunks,  which 
pass  upward  along  the  edge  of  the  pectoral  muscle  and  empty  into  the 
axillary  nodes.  The  first  node  of  this  axillary  chain  lies  on  the  third  rib, 
beneath  the  pectoralis  major.  There  are  about  a  dozen  axillary  lymph- 
nodes.  The  more  important  are  grouped  about  the  axillaiy  vein,  where 
it  receives  its  long  thoracic  and  subscapular  tributaries.  Some  of  the 
lower  cervical  nodes,  lying  close  above  the  clavicle,  have  h-mph  con- 
nections with  the  axillary  nodes,  and  the  deep  lymph-nodes  in  the  retro- 
mammary fat  may  communicate  directly  with  the  breast  tissue.     For 

1  J.  Collins  Warren,  The  Surgeon  and  the  Pathologist,  Jour.  Amor.  Med.  Assoc, 
July  16,  1905. 


CANCER   OF  THE    BREAST 


507 


convenience  of  gross  anatomic  description  the  breast  is  spoken  of  as 
divided  into  hemispheres  and  quadrants — tlie  upper,  the  lower,  the 
outer,  the  inner,  etc. 

CANCER   OF   THE  BREAST 

Cancer  of  the  breast  is  common.  After  the  stomach  and  the  uterus, 
the  female  breast  more  often  than  any  other  organ  is  the  site  of  cancer. 
Cancer  is  the  most  frequent  tumor  of  the  breast — far  more  common  than 
benign  tumors.  Statistics  vary.  Authors  estimate  the  frequency  of 
cancer  as  between  70  and  82  per  cent,  of  all  breast  tumors.  Not  only 
does  cancer  develop  primarily,  but  frequently  it  appears  as  the  outcome 
of  changes  in  tumors  heretofore  benign.  This  is  not  the  place  for  a  dis- 
cussion of  that  burning  question,  the  etiology  of  cancer,  but  clinicians 
have  come  to  think  that  breast  cancer,  like  cancer  elsewhere,  may  in 
some  degree  be  dependent  upon  trauma — not  trauma  in  the  ordinary 


Fig.  317. — Acinous  and  duct  cancer  (Warren  Museum,  Harvard). 

sense  of  wound  or  bruise,  but  trauma  in  the  sense  of  long-continued  irri- 
tation, such  as  any  actively  functionating  part  must  undergo. 

Cancer  of  the  breast,  in  most  cases,  springs  from  the  epithelium  lining 
the  acini  or  from  the  epithelium  lining  the  ducts.  Hence  the  familiar 
terms,  acinous  cancer  and  duct  cancer.  Acinous  cancer  is  far  the  more 
common.  That  is  a  histologic  classification,  but  old-time  convention 
has  established  a  clinical  classification  which  is  still  in  common  use 
among  surgeons.  For  instance,  we  speak  of  scirrhus  and  medullary 
cancer  (or  encephaloid) ,  of  colloid,  of  atrophic  caricer,  of  cancer  ew  cuirasse 
and  of  Paget's  disease. 

By  scirrhus  we  mean  a  hard  growth  merely,  and  this  hardness  is  due 
to  the  fact  that  the  tumor  contains  much  connective  tissue  and  little 
parenchyma.  Medullary  cancer  is  softer,  because  it  contains  much  par- 
enchyma and  little  connective  tissue.  When  the  tumor  undergoes  col- 
loid degeneration,  we  speak  of  it  as  colloid  cancer.  Atrophic  cancer, 
or  "  withering  scirrhus,"  produces  so  great  a  shrinking  of  the  gland  that 


508 


THE    CHEST 


little  of  the  breast  can  be  found.  Then  there  is  the  so-called  cancer  en 
cuirasse  of  Virchow,  which  shows  itself  as  a  malignant  growth  involving 
extensively  the  lymphatics  of  the  skin,  as  well  as  the  thoracic  wall.  A 
considerable  area  of  the  chest  seems  to  beset  in  a  wide-reaching,  firm 


^ 


^ 


Fig.   318. — External  appearance    of    scirrhous   carcinoma    (Massachusetts  General 

Hospital). 

corslet  of  disease.  Paget's  disease  of  the  nipple  is  a  somewhat  rare 
condition,  which  leads  to  malignant  involvement  of  the  mammary  gland. 
It  starts  as  a  chronic  inflammation,  suggesting  eczema  of  the  nipple 
and  areola,  and  may  last  several  years.     It  is  not  a  simple  eczema,  and 


Fig.  319. — Section  of  scirrhous  carcinoma  (Warren  Museum,  Harvard). 

does  not  yield  to  ordinary  treatment.  If  left  unchecked,  it  proceeds 
frequently  to  invasion  of  the  epithelium  lining  the  mammary  ducts, 
until  it  produces  a  genuine  duct  cancer,  with  all  the  familiar  charac- 
teristics of  that  affection. 


CANCER    OF   THE    BREAST 


509 


Cancer  of  the  breast,  like  cancer  elsewhere,  has  no  capsule.  It 
progr(\sses  by  a  general  infiltration,  though  the  different  forms  of  cancer 
vary  in  their  life-history,  in  their  symptoms,  and  other  manifestations. 


Fig.  320. — External  appearance  of  medullary  cancer  (Massachusetts  General  Hos- 
pital). 

Scirrhus  grows  slowdy,  and  may  run  a  course  of  two  or  three  years.     It  is 
most  common  in  women  who  have  borne  children.     Though  not  peculiar 


Fig.  321. — Section  of  medullary  cancer  (Warren  Museum,  Hars^ard). 

to  old  women,  it  appears  usually  after  middle  life.  The  tj^pical  forms 
of  atrophic  scirrhus  are  peculiar  to  persons  of  advanced  years.  Med- 
ullary cancer  is  more  common  to  persons  in  young  middle  life,  and  is 


510 


THE    CHEST 


found,  rarely,  among  younji;  women  oven.  I  have  seen  medullary  cancer 
develop  ra])idly  in  an  unmarried  ^ii'l  of  twenty-on(\  Medullary  cancer 
may  kill  the  i)atient  within  a  year.     Thi.s  i.s  the  foi-m  wliich  early  attacks 


Fig.  322. — External  appearance  of  colloid  cancer  (Massachusetts  General  Hospital). 

the  skin  and  underlying  muscles,  and  results  in  the  familial'  ulcerating, 
cauliflower  growths,  which  the  laity  usually  associate  with  cancer  of  the 
breast.     Not  long  ago  I  had  under  my  care  a  stout  woman  of  forty,  the 


Fig.  323. — Section  of  colloitl  cancer  (Warren  Museum,  Harvard  University). 

victim  of  one  of  these  tumors,  which  had  destroyed  the  breast  and  a  large 
part  of  the  pectoralis  major.  It  presented  the  appearance  of  a  great 
granulating  wound  the  size  of  a  dinner  plate,  and  with  foul,  elevated 
edges. 

The  progress  of  all  forms  of  breast  cancer  is  continuous.     They 


CANCER    OF   TIIK    HHKAST 


511 


invade  early  the  neighboring!;  lyniph-notle.s,  especially  those  in  the  ax- 
illaiy  grou)),  whence  the  disease  sjjreads  to  the  lower  cervical  group. 


Fig.  324. — Adenocarcinoma  (Warren  Museum,  Harvard  University). 

Late,  and  more  rarely,  the  subpectoral  and  the  mediastinal  nodes  be- 
come  involved.     The   patient   dies   with   distinct   metastases   often — 


Fig.  325. — Cancer  en  cuirasse. 

cancer  of  the  lung  and  pleura,  of  the  Hver.  the  spinal  column,  or  the 
brain.     The  exact  method  of  cancer  dissemination  is  still  a  matter  of 


512 


THE   CHEST 


discussion,  and  Handlcy*  recently  has  advanced  views  at  variance  with 
those  commonly  accepted,  namely,  the  belief  in  a  spread  throufih  the 
blood  and  lymph-channels  only.  He  asserts  that  the  dissemina- 
tion of  cancer  is  accomplished  in  a  more  slow  and  subtle  way  \)y  the 
actual  growth  of  cancer-cells  in  all  directions,  from  the  tumor  center 
along  the  finer  vessels  of  the  lymphatic  plexuses.  The  author  calls  this 
"  permeation,"  and  states  that  it  takes  place  as  readily  against  the 
lymph-stream  as  with  it.  In  this  way  the  tissues  ai-e  involved  as  by 
an  invisible  annular  ring-worm,  the  growth  extending  like  a  ripple,  in  a 
wider  and  wider  circle,  with  a  healing  process  going  on  within  its  cir- 
cumference, leaving  behind   it   involved   lymph-nodes  which   persist. 


y.'& 


— .     n 


Fig.  326. — Paget's  disease  (Massachusetts  General  Hospital). 

Thus  he  says  a  breast  cancer  with  its  invisible  microscopic  extension 
forms  a  mass  shaped  somewhat  like  a  biconvex  lens,  the  thin  circum- 
ference of  the  lens  situated  often  far  beyond  the  limits  of  the  bn^ast, 
is  formed  by  the  cancer-filled  lymphatics  of  the  fascial  lymph-plexus, 
and  lies,  as  a  rule,  exclusively  in  the  plane  of  this  plexus.  As  one  ap- 
proaches the  center  of  the  lens,  which  center  corresponds  to  the  primary 
growth,  the  adjoining  layers  of  tissue  are  invaded  by  cancer  to  a  grad- 
ually increasing  depth.  However  this  may  be,  the  surgeon  in  practice 
discovers  clinically  a  mass  in  the  breast  and  enlarged  nodes  in  the  axilla, 
but  he  may  be  sure  that  the  region  between  the  primary  growth  and  the 
nodular  metastases  is  itself  the  site  of  microscopic  cancerous  involve- 
ment. 

Cancer  occurs  in  the  male  breast  also,  springing  from  the  nidimen- 
•  W.  S.  Handley,  Glascow  Med.  Jour.,  December,  1905. 


CANCER    OF   THE    BREAST  513 

tary  glandular  epithelium.  It  is  rare  in  men,  though  its  exact  frequency 
is  somewhat  undetermined.  1  have  seen  one  male  breast  cancer  in  a 
group  of  72  cancers  of  the  breast.  The  figures  usually  given  are  1  in 
100. 

Surgical  literature  abounds  in  protest  against  the  common  conceal- 
ment of  breast  cancer  practised  by  women,  and  it  is  hard  to  see  why  the 
victims  of  this  disease  so  frecjuently  attempt  to  keep  all  knowledge  of  it 
from  their  families  and  from  their  physicians  even.  We  are  coming 
to  believe,  however,  that  modem  teaching  and  the  insistence  by  our 
profession  on  the  importance  of  early  treatment  are  tending  to  abolish 
the  old-time  unhappy  tradition  of  secrecy.  Cancer  of  the  breast  was 
formerly  regarded  as  a  horror  for  which  there  was  no  hope.  To-day 
we  know  that  an  increasing  proportion  of  these  cases  are  cured  by 
operation. 

The  symptoms  of  cancer  of  the  breast  are  elusive  often,  rarely  char- 
acteristic in  the  early  stages  of  the  disease,  sometimes  not  obvious  to  the 
patient  until  the  growth  has  developed  far.  The  symptoms  depend 
on  the  age  of  the  patient,  the  location  of  the  tumor,  and  the  histologic 
nature  of  the  growth.  Unfortunately,  the  symptoms,  of  diverse  char- 
acter, are  never  a  sure  indication  of  the  exact  nature  of  the  growth, 
even  though  its  malignancy  be  assured.  We  look  for  the  following 
symptoms  and  signs:  pain,  tumor,  dimpling  of  the  skin,  ulceration,  re- 
traction of  the  nipple,  involvement  of  lymph-nodes.  The  pain  may  be 
early  and  may  be  the  first  indication  of  trouble.  It  may  be  dull  and 
boring,  or  it  may  be  lancinating  and  shooting,  or  there  may  be  a  stitch 
in  the  side,  running  into  the  shoulder  and  upper  arm.  Or  there  may 
be  no  pain  for  long,  but  a  tumor  may  be  the  first  evidence  of  trouble. 
A  woman,  robust  and  vigorous,  may  consult  the  surgeon  and  state 
that  she  has  discovered  recently  a  painless  lump  in  her  breast.  The 
surgeon  must  examine  the  lump  with  suspicion,  no  matter  what 
the  age  of  the  patient,  and  he  must  not  be  misled  if  the  lump  be 
found  in  that  detached  portion  of  the  gland  lying  high  toward  the 
axilla.  A  cancer,  small  and  deeply  placed,  is  always  fixed  in  the 
breast;  it  is  not  encapsulated,  and  cannot  be  moved  about.  If  deep, 
it  may  not  be  felt  by  the  examining  hand  lifting  the  breast  in  front. 
The  surgeon  should  stand  behind  the  sitting  patient,  and  with  his 
hand  over  her  shoulder  should  roll  under  his  fingers  the  breast,  flat- 
tened against  the  chest,  when  he  will  find  an  infiltrating  mass  pre- 
viously undetected.  On  the  other  hand,  most  cancers  of  the  breast 
are  easily  palpable  on  the  patient's  first  visit  to  the  surgeon,  and  fre- 
quently the  condition  is  only  too  apparent.  As  the  disease  advances 
the  skin  over  the  mass  becomes  pitted;  later  it  breaks  down  in  an 
ulceration;  the  nipple  frequently  retracts,  and  enlarged  nodes  in  the 
axilla  become  apparent.  An  increasing  cachexia  accompanies  those 
local  signs  of  trouble.  Appetite  and  strength  fail,  slowly  at  first,  rapidly 
toward  the  end.  There  has  been  much  discussion  regarding  the  time 
in  the  progress  of  the  disease  at  which  enlargement  of  the  lymph-nodes 
occurs.     Older  surgeons  have  gone  so  far  as  to  assert  that  these  nodular 

33 


514  THE    CHEST 

metastases  do  not  appear  until  the  parent  growth  is  a  year  old.  Prob- 
ably this  is  not  true.  The  time  of  appearance  of  enlarged  nodes  depends 
upon  the  character  and  rate  of  growth  of  the  cancer.  Mor(H)ver,  one 
observer  may  discover  euhirged  nodes  undetected  by  another.  In  order 
to  find  axillary  nodes,  sit  before  the  patient,  whose  arm  should  be  raised, 
and  press  your  fingers  high  into  the  axilla,  with  the  palm  of  your  hand 
against  her  chest.  Then  bring  the  patient's  arm  down  to  her  side. 
One  may  detect  palpable  nodes  against  the  ribs  and  along  the  lo\\er 
margin  of  the  pectoralis  major.  Late  in  the  disease  the  cervical  and 
clavicular  nodes  become  involved.  In  the  breast  a  single  mass  only  can 
be  felt,  as  a  rule.  Rarely  two  tumors  are  present,  and  the  surgeon  should 
never  fail  to  examine  the  opposite  breast  also.  In  nearly  7  per  cent,  of 
the  cases  both  breasts  are  involved. 

The  surgeon  founds  his  diagnosis  upon  the  evidence  of  a  tumor,  pain, 
and  involvement  of  lymph-nodes.  The  characteristic  cachexia  is  a  late 
symptom.  In  many  cases  one  is  in  doubt  as  to  the  diagnosis,  especially 
when  the  only  evidence  of  disease  is  the  tumor.  In  such  case,  no  matter 
what  the  age  of  the  patient  or  the  character  of  the  mass,  the  surgeon 
should  be  extremely  cautious  in  pronouncing  against  cancer,  and  should 
give  a  favorable  diagnosis  of  benign  tumor  only  when  such  a  diagnosis 
of  benign  growth  is  clear.  If  there  be  the  least  doubt,  he  should  ex- 
plore the  breast  by  the  method  of  plastic  resection  which  I  shall 
describe,  should  have  the  tumor  examined  immediately,  and  should 
proceed  with  the  radical  operation  if  it  prove  to  be  malignant.^  It 
is  a  safe  rule  to  remove  all  tumors  of  the  breast  in  w^omen  thirty-five 
or  more  years  old. 

The  prognosis  of  breast  cancer  unremoved  is  always  positively  bad, 
and  the  duration  of  the  disease  before  death  depends  on  the  age  of  the 
patient  and  the  nature  of  the  cancer.  Medullary  cancer  may  kill  a 
woman  of  forty  in  a  year.  A  woman  of  seventy  may  live  with  a  scirrhus 
for  three  or  more  years.  The  prognosis  after  operation  I  shall  discuss 
in  a  later  paragraj^h. 

The  treatment  of  cancer  of  the  breast  is  by  radical  operation.  There 
is  not  the  slightest  evidence  that  other  methods  of  treatment  offer  a  hope 
of  cure.  Twenty-five  years  ago  the  profession  was  still  convinced  that 
removal  of  the  tumor  by  operation  was  a  desperate  measure,  but  within 
the  last  fifteen  years  the  results  of  such  radical  operators  as  Halsted, 
Joerss,  Rotter,  Cheyne,  Warren,  and  many  others  have  forced  the  con- 
viction that  breast  cancer  taken  early  and  thoroughly  excised  do€s  not 
return.  The  statistics  of  permanent  cures  under  the  treatment  of  com- 
peteht  surgeons  vary  all  the  way  from  19  to  42  per  cent.  It  is  an  in- 
teresting fact  that  local  recurrences  take  place  commonly  in  the  scar  or 
skin  over  the  chest  and  not  in  the  axilla.  All  reliable  surgeons,  with  one 
or  two  exceptions,  are  now  agreed  that  the  dissection  should  be  far- 
reaching  and  thorough,  and  should  involve  removal  not  only  of  the  whole 

*  I  deprecate  stronfjly  the  use  of  the  exploratory  punch  sometimes  advocated, 
since  it  may  bring  away  portions  of  the  cancerous  mass,  and  cause  the  rapid  in- 
volvement of  overlying  skin. 


CANCER  OF  THE  BREAST  515 

breast,  but  of  its  overlying  skin,  a  wide  zone  of  adjacent  fat  tissue,  both 
pectoral  muscles  and  the  fat  and  nodes  of  the  axilla.  A  routine  attack 
upon  the  clavicular  and  cervical  nodes  seldom  is  advocated.  The  dis- 
section 1  have  described  implies  an  opcu-ation  of  great  gravity — an  opera- 
tion re(piiring  time  and  care,  involving  considerable  loss  of  blood,  shock 
often,  sometimes  extensive  plastic  repair  of  the  wound,  a  slow  con- 
valescence, and  more  or  less  permanent  crippling  of  the  arm  on  the 
affected  side. 

Such  in  general  terms  is  the  problem  before  the  surgeon;  and  so 
wide  a  removal  of  tissue  seems  necessitated  from  our  conviction  that 
cancer  involves  parts  beyond  any  obvious  macroscopic  lodgment,  that 
its  microscopic  presence  may  be  found  in  the  skin,  in  the  tymph-spaces, 
in  the  fat,  and  in  the  underlying  aponeurosis  and  muscles.  J.  B.. 
Murphy  alone  of  recognized  authorities  maintains  that  a  removal  of  the 
pectoral  muscles  seldom  is  necessary,  because  the  growth,  when  taken 
early,  does  not  penetrate  beyond  the  aponeuroses. 

Operation  for  Cancer  of  the  Breast. — The  radical  operation  for 
removal  of  breast  cancer  is  the  only  operation  seriously  to  be  consid- 
ered if  one  anticipates  a  cure,  though  we  may  observe  in  passing  that 
sometimes  the  surgeon  dealing  with  hopelessly  extensive  cancer  may 
think  it  best  to  do  a  palliative  resection  with  the  purpose  merely  of  con- 
verting a  foul,  ulcerating  area  into  a  clean  wound.  Numerous  radical 
operations  in  recent  years  have  been  devised,  but  all  of  them  follow 
essentially  the  rules  laid  down  by  Halsted.^  The  variations  in  detail 
from  Halsted's  technic  aim  merely  at  treating  the  axilla  so  as  to  pro- 
duce less  impairment  of  the  arm's  function,  and  at  attacking  the  mal- 
ignant mass  at  some  novel  point.  For  several  years  I  followed  that 
method  of  procedure  to  which  Warren's^  name  is  attached.  As  Warren 
points  out,  we  cannot  observe  anatomic  landmarks  or  regard  cosmetic 
effects  when  dealing  with  cancer,  for  cancer  invades  tissues  indiscrimin- 
ately, and  the  surgeon  with  his  knife  in  like  manner  must  invade  them 
if  he  hopes  to  extirpate  the  disease;  he  must  remove  the  entire  growth 
with  a  wide  margin,  cutting  into  muscle,  skin,  aponeurosis,  bone,  vas- 
cular and  lymphatic  connections  wherever  he  has  reason  to  suppose 
they  are  involved  in  the  cancer.  I  used  with  satisfaction  and  for  many 
years  the  following  technic:  Enter  the  knife  at  the  shoulder  and  carry 
it  down  toward  the  outer  border  of  the  breast  along  the  anterior  axillary 
fold,  and  about  two  inches  to  the  inner  side  of  it  at  the  start.  Sweep 
around  the  outer  and  lower  border  of  the  breast  at  the  circumference  of 
that  organ.  Warren  points  out  that  at  this  stage,  if  the  operator  is  in 
doubt  as  to  the  nature  of  the  growth,  he  can  turn  up  the  breast  from 
below  and  excise  a  portion  of  the  tumor  for  microscopic  examination. 
Having  determined  that  the  growth  is  malignant,  the  surgeon  now  com- 
pletes his  sweep  about  the  breast,  and  brings  his  cut  up  on  the  inner 
side  to  meet  the  original  incision  on  a  level  with  the  axilla;  he  thus  forms 

1  W.  S.  Halsted.  Ann.  Surg.,  November,  1894. 

2  J.  C.  Warren,  The  Operative  Treatment  of  Cancer  of  the  Breast,  Ann.  Surg., 
December,  1904. 


m 


THE    CHEST 


a  racket-shaped  wound  of  great  extent,  the  edges  of  which  he  will  prob- 
ably  be  unable  to  bring  together.  Next,  with  a  view  to  the  ultimate 
closmg  of  the  wound,  he  marks  out  a  supplementary  Hap  low  in  the 
axilla,  such  as  is  shown  in  Fig.  327.  In  order  to  provide  for  a  possible 
dissection  of  the  cervical  triangles  he  marks  out  also  a  third  incision 
running  into  the  neck. 


r 


Fig.  327. — Warren's  operation  for  amputation  of  the  breast — step  1. 

The  second  step  in  the  operation  is  freely  to  turn  back  the  skin  on 
all  sides  and  to  dissect  up  the  supi)lementary  axillary  flap.  This  dissec- 
tion should  be  carried  high  enough  in  the  neck  to  expose  the  clavicle. 
One  now  sees  an  extensive  wound,  shaped  somewhat  like  a  tnuicated 
cone,  the  untouched  breast  representing  the  base,  with  a  considerable 
expanse  of  fat  and  muscle  tapering  off  toward  the  axilla. 

The  third  stage  in  the  operation  consists  in  removing  entire  the  ex- 
posed suspicious  tissues.     Begin  the  deep  dissection  above,  and  turn 


CANCER   OF  THE    BREAST 


517 


in  the  ^vholc  mass  toward  the  stcM-nal  side.      Strip  up  with  the  finger 
the  insertion  of   the  pectoralis  major  toward   the   humerus    (leaving 


Fig.  328.— Warren's  operation  for  amputation  of  the  breast— step  2. 


Fig.  329.— Warren's  operation  for  amputation  of  the  breast— step  3. 

the  clavicular   portion),   and   cut  away  the   muscle   near    the  bone. 
Turn  down  the  severed  pectoraHs  major  and  expose  the  insertion  of  the 


518 


THE    CHEST 


pectoralis  minor;  cut  this  away  close  to  the  scapula.  Ihon,  by  firni 
retraction  downward  and  inward,  the  surgeon  exposes  readily  the  axilla. 
He  clamps  the  larger  arteries  and  veins  and  cuts  them  away  close  to  the 
axillary  vessels,  after  which,  rapid  dissection  with  the  knife  and  fingers 
exposes  the  posterior  muscles  and  the  serratus.  The  deep  nmscular  at- 
tachments are  now  freed  completely  down  to  the  ribs,  when  it  is  an  easy 
matter  to  peel  off  by  quick  dissection  the  whole  disease-mass  toward  the 
sternum,  removing,  as  one  goes,  both  pectoral  muscles.  After  this  a 
further  cleaning  of  the  parts  high  in  the  axilla  may  he  done  if  needful, 
and  a  supplementary  dissection  of  the  cervical  triangles  through  turn- 


J 


/ 
Fig.  3.30. — Warren's  operation  for  amputation  of  the.  breast — step  4. 

ing  back  the  neck  flap  as  I  have  indicated.  It  remains  to  close  in  the 
great  wound,  Avhich  can  scarcely  be  done  without  utilizing  the  supple- 
mentary axillary  flap.  The  figures  show  how  easily  and  perfectly  one 
may  accomplish  this,  as  a  rule.  I  recommend  draining  the  wound  with 
a  cigaret  wick  in  the  axilla  for  twenty-four  hours. 

Extensive  scar-formation  in  the  axilla  may  follow  this  operation — 
scar-formation  which  cripples  seriously  the  action  of  the  arm.  The 
surgeon  should  endeavor,  so  far  as  possible,  to  obviate  this  condition  by 
tucking  the  lower  skin-flap  high  into  the  axilla  and  securing  it  there  with 
a  buried  stitch.     In  consideration  of  the  possibility  of  trouble  with  the 


CANCER  OF  THE  BREAST  519 

urm  Murphy  ^  advocates  certain  muscle-plastic  procedures  which  are 
interesting.  He  points  out  that  undesirable  results  of  removal  of  the 
breast  as  commonly  done  are:  (1)  Fixation  of  the  arm  to  the  chest,  with 
more  or  less  limitation  of  motion;  (2)  venous  stasis  in  the  arm  and  fore- 
arm with  edema;  (3)  pseudoelephantiasis ;  (4)  neuralgia  in  the  arm  and 
forearm;  (5)  sensitive  retracting  scars.  In  order  to  forestall  these  cal- 
amities Murphy  advises  dressing  the  arm  at  a  right  angle  to  the  chest  and 
supporting  it  in  a  plaster  splint  during  the  early  days  of  convalescence, 
and  the  interposing  of  muscle  slips  between  the  axillary  vessels  and  the 
axillary  skin.  His  arguments  are  ingenious  and  suggestive,  and  his 
methods  appear  feasible.  He  uses  long  and  broad  slips  from  the  pector- 
alis  major  or  latissimus  dorsi.  He  justifies  his  use  of  the  pectoralis 
major  by  asserting  that  its  entire  removal  with  the  breast  is  needless, 


Fig.  331. — Warren's  operation  for  amputation  of  the  breast — step  5. 

"  as  the  aponeurosis  and  not  the  muscle  carries  the  lymphatics  in  which 
metastases  occur."  Most  operators,  while  agreeing  in  part  with  Murphy 
in  this  contention,  will  protest  that  no  man  may  say  whether  or  not  the 
pectoralis  major  muscle  itself  is  involved  in  the  disease.  The  use  of  the 
latissimus  dorsi,  however,  seems  free  from  this  objection,  and  the  ap- 
plication of  the  plaster  bandage  with  the  arm  held  out  from  the  side 
promises  much.  On  the  other  hand,  the  disabilities  rehearsed  by  Murphy 
are  not  so  common  as  he  might  lead  us  to  suppose.  Careful  surgeons 
endeavor  to  fill  in  snugly  the  axillary  gap  after  the  dissection,  and  excel- 
lent function  of  the  arm  under  the  old  methods  is  the  rule.  I  find  that, 
by  the  careful  obliteration  of  dead  spaces,  by  draining  the  axilla  for 
twenty-four  hours,  by  padding  abundantly  the  axilla  so  as  to  hold  the 

1  J.  B.  Murphy,  Axillary  and  Pectoral  Cicatrices  Following  the  Removal  of  the 
Breast,  Axillary  Glands,  etc.,  New  York  Med.  Jour.,  January  6,  1906. 


520 


THI-:    CHEST 


arm  well  out  from  the  side,  and  by  the  curly  use  of  passive  movements  I 
encounter  rarely  those  disabilities  which  have  been  mentioned. 

The  (iftcr-trcattucnt  and  a  long-continued  following  up  of  these  cases 
are  important.  One  should  get  the  patients  out  of  bed  at  the  end  of  a 
week — not  earlier,  because  early  moving  about  may  dislodge  a  thrombus, 
with  a  fatal  result,  as  in  one  of  A^'arren's  reported  cases.  In  the  second 
week  of  convalescence  one  should  begin  passive  movements  and  massage, 
and  kee])  up  this  treatment  persistently  for  a  month  or  long(!r.  After 
the  patient's  health  has  been  restored,  she  should  make  periodic  visits  to 
the  surgeon  for  at  least  three  years,  that  he  may  inspect  the  scar  to 
discover  possible  recurrence  of  the  disease.  At  the  same  time  he  should 
investigate  the  patient's  spine,  lungs,  and  other  viscera.  Nothing  can 
be  done  with  the  knife  for  internal  metastases,  but  local  recurrence  often 
may  be  treated  by  excision.     The  outlook  after  such  thorough  removal 


■■j^^cJ**?^'- 


/?^^>/i<£Jr/^ 


Fig.  332. — Line  of  incision  for  brea.st  operation  (Jackson'.s  method). 

of  breast  cancer  is  increasingly  favorable,  as  I  have  said,  and  in  direct 
proportion  to  the  prom])tness  and  early  date  of  the  operation. 

I  have  described  in  detail  the  steps  of  Warren's  operation,  pointing 
out  that  its  principles  coincide  with  those  of  all  radical  operations  on 
the  breast.  Sundry  other  incisions  and  steps  are  advocated  by  other 
writers.  Halsted's  classic  and  pioneer  work  is  not  to  be  forgotten. 
His  incision  essentially  is  followed  by  Warren,  but  Halsted  turns  out 
the  dissected  mass  toward  the  axilla  instead  of  inward  toward  the  ster- 
num. Kocher  advocates  an  interesting  incision  the  outlines  of  which 
suggest  a  reversed  figure  6.  ^^'illy  Meyer  *  long  ago  described  and  advo- 
cated an  operation  similar  to  that  I  have  given  in  detail,  and  Jackson  - 

1  Jour.  Amer.  Med.  Assoc.  July  29,  1905. 

2  Jabez  N.  Jackson,  ibid.,  March  .3,  1906. 


CANCEll    OF    THE    UUEAST 


521 


Fig.  333. — External  appearance  of  cancer  of  breast.     Removed  by  Jackson's  method 

(personal  case). 


Fig.  334. — Operation  for  cancer  of  the  breast;  shows  pectoralis  major  muscle  (per- 
sonal case). 

describes  an  interesting  incision  which  I  have  now  adopted ;  but  it  is 
needless  further  to  enumerate  the  countless  modifications  and  sugges- 
tions upon  this  subject  by  recent  writers. 


522 


THE    CHEST 


In  spite  of  tho  improvement  in  our  statistics  surgeons  have  not  rested 
content  with  the  results  of  radical  breast  operations,  and  numerous 
and  carefully  conducted  investigations  on  other  lines  of  treatment  con- 
stantly are  being  made.  So  far  such  endeavors  have  accomplished 
little.  The  a:-rays,  violet  rays,  and  radium  are  nearly  valueless,  though 
they  may  relieve  pain;  and  the  much-vaunted  trypsin  injections  of  Beard 
are  not  making  good  the  claims  of  their  original  advocate.  A  few  j'ears 
ago  Beatson's  operation^  seemed  to  promise  something.  Beatson's  opera- 
tion consists  in  removing  the  ovaries  for  the  supposed  effect  which  the 
loss  of  those  organs  has  upon  the  epithelial  cells  in  the  breast.  Al- 
though a  few  cases  of  notable  improvement  in  breast  cancer  following 
Beatson's  operation  have  been  reported,  the  number  of  successes  by 
this  method  arc  too  few  to  warrant  confidence  in  the  jjiocedure. 


ctcil   f personal  case). 


AMiile  cancer  is  that  form  of  breast  timior  most  interesting  and  im- 
portant because  of  its  frequency  and  fatality,  numerous  other  new- 
growths  are  to  be  found  in  the  breast,  some  of  them  benign,  some  of 
them  doubtful,  some  of  them  truly  malignant.  Fibroma  is  a  common 
tumor  of  the  benign  class;  sarcoma  is  a  somewhat  rare  tumor  of  the 
malignant  class.  Most  of  these  non-cancerous  tumors  are  allied  to 
each  other  in  structure  and  origin,  so  that  a  brief  consideration  of  the 
whole  class  simis  up  for  us  our  knowledge  of  breast  tumors  other  than 
cancer.  In  a  previous  paragraph  I  spoke  of  a  characteristic  myxomatous 
connective  tissue  which  develops  about  the  terminal  ducts  and  acini  of 
the  normal  breast,  it  is  with  this  periductal  connective  tissue  that  we 
^  Jour.  Amer.  Med.  Assoc,  editorial,  September  2,  1905. 


CANCER    OF   THE    I?i;EA,ST  523 

have  to  deal  when  we  consider  benign  breast  tumors,  and  I  avail  myself 
of  J.  C.  Warren's  admirable  classification,  to  which  I  have  already 
refcrretl.  Warren  points  out  that,  owing  to  the  intimate  association  of 
the  periductal  tissue  with  the  epithelium  lining  the  ducts,  all  tumors 
of  the  mammary  gland  contain  some  of  the  elements  and  take  on  some 
ot  the  characteristics  of  both  connective-tissue  and  epithelial  growths. 


Fig.  336. — Large  cancer  of  breast  (personal  case).     External  appearance  of  breast 
after  removal  (reduced).     Length,  13  in.;  width,  10^  in. 

Bloodgoocl  ^  also  deals  at  length  with  this  subject  in  an  illuminating 
article.     Warren  gives  the  following  table  of  breast  tumors: 

"  Carcinoma  (already  considered). 
Fibro-epithelial  tumors : 

(1)  Fibrous  type: 

1.  Periductal  fibroma. 

2.  Periductal  myxoma. 

3.  Periductal  sarcoma. 

(2)  Epithelial  type  (cystadenoma)  : 

1.  Fibrocystadenoma. 

2.  Papillary  cystadenoma. 

Hyperplasia: 

1.  Diffuse  hypertrophy. 

2.  Abnormal  involution. 
Cystic. 
Proliferative. 

1  J.  C.  Bloodgood,  Senile  Parenchymatous  Hypertrophy  of  Female  Breasts,  Its 
Relation  to  Cyst  Formation  and  Carcinoma,  Surg.,  Gyn.,  Obstet.,  December,  1906. 


524  THE    CHEST 

Chronic  inflammation: 

1.  Eczoma  of  nipple. 

2.  Chronic  abscess. 

3.  Ductal  mastitis. 

4.  Tubcrculosi.s. 

5.  Single  retention  cyst. 

Non-indigenous  tumors: 

1.  Sarcoma. 

2.  Lipoma. 

•i.  Lympiiangioma. 
Supernumerary  breast." 

Periductal  fibromata,  myxomata,  and  sarcomata  all  are  closely 
allied,  and  one  must  observe  the  fact  that  the  "  chief  constituent  of  the 
tumors  of  the  fibrous  type  is  the  peculiar,  transparent,  periductal 
tissue  of  the  female  breast."  We  may  reserve  the  name  "  adeno-'  for 
those  tumors  in  which  the  epithelial  elements  play  the  important  part. 
Cystic  dilatation  of  the  ducts  or  of  the  characteristic  clefts  of  the  peri- 
ductal fibroma  may  occur,  and  is  probably  due  to  the  obstruction  of 
preexisting  ducts.  The  cysts  thus  formed  are,  therefore,  secondary; 
and  the  tumors  may  be  divided,  according  to  their  richness  in  cells  or 
the  character  of  their  fibrous  tissue,  into  the  three  groups,  fibroma, 
myxoma,  and  sarcoma. 

OTHER   BREAST   TUMORS 

Periductal  fibromata  of  the  breast  (intracanalicular  papillary 
fibromaj  are  encapsulated  tumors,  varying  in  size  from  a  bean  to  a 
cocoanut.  They  are  single  or  multiple;  sometimes  they  contain  cysts. 
They  are  firm,  white,  and  glistening  in  appearance  on  section.  Com- 
monly they  are  found  in  women  between  twenty  and  thirty  years  of 
age.  The}'  grow  slowly;  generally  they  are  painless,  though  they  may 
be  sensitive  at  the  menstrual  period,  and  most  frequently  they  lie  in  the 
upper  outer  quadrant  of  the  breast . 

Periductal  myxomata  differ  little  in  their  structure  from  the 
fibromata.  AYe  assign  them  to  a  special  group  because  they  appear 
larger,  as  a  rule,  and  are  composed  of  a  myxomatous  fibrous  tissue, 
identified  by  a  local  edema.  They  are  tumors  of  middle-aged  women; 
are  almost  always  hard;  sometimes  necrotic;  sometimes  associated  with 
enlargement  of  the  axillary  nodes.  Nearly  always  containing  cyst 
cavities,  they  differ  from  the  previous  class  in  no  important  respect. 

Periductal  sarcomata  constitute  the  third  group  of  periductal  tu- 
mors, and  present  the  combination  of  a  richly  cellular  stroma  mingled 
with  epithelial  gland-ducts.  These  are  large  tumors;  hard,  often  in- 
volving the  whole  breast,  and  reaching  the  size  of  a  child's  head.  They 
are  lobulated  and  encapsulated;  often  they  contain  cysts,  and  frequently 
they  are  ulcerated.  The  overlying  skin  is  reddened  and  is  traversed  by 
dilated  veins,  but  it  is  not  always  adherent.  Rarely  the  axillary'  nodes 
are  involved.  These  sarcomata  are  most  common  in  middle-aged 
married  women,  and  cause  discomfort  from  their  size  rather  than  from 
pain. 


OTHER    BUr-^AST   TUMORS 


525 


The  treatment  of  these  three  types  of  tumor  is  obvious.  Fibromata 
and  myxomata  demand  local  removal  of  the  growth  only,  while  the 
sarcomata  require,  in  addition,  amputation  of  the  breast  and  dissection 
of  the  axilla.  So  much  for  fibro-epithelial  tumors  of  the  fibrous  type. 
There  is  another  class  belonging  to  the  fibro-epithelial  group,  however, 
characterized  by  a  conspicuous  development  of  the  epithelial  or  duct 
elements  in  the  breast.     This  is  the — 

Epithelial  Type  {C ystadenomata) . — These  tumors  are  benign,  as  a 
rule,  though  they  belong  to  the  epithelial  type.  Warren  describes  them 
as  adenomata  (fibrocystadenomata  and  papillary  cystadenomata),  and 
their  name  describes  graphically  their  structure;  they  are  not  especially 
common. 


Fig.  337. — Periductal  myxoma  (W.  P.  Graves). 

Fibrocystadenomata  are  made  up  of  periductal  fibrous  tumors  con- 
taining secondary  epithelial  new-growths.^  They  occur  usually  in 
young  single  women.  They  grow  slowly  and  cause  little  pain.  In  ex- 
tent they  vary  from  the  size  of  a  walnut  to  that  of  a  fist.  They  are 
lobular,  hard,  and  movable.  The  axillary  nodes  are  not  involved.  They 
are  encapsulated  and  show  a  lobular  structure  containing  cysts  of  vari- 
ious  sizes,  the  cj^sts  showing  papillary  outgrowths  of  connective  tissue 
covered  with  epithelium.  The  gland-ducts  rather  than  the  acini  are 
involved. 

We   must   regard   these   fibrocystadenomata   as   approaching   the 

1  These  are  tumors  variously  described  as  adenomata,  papillary  cystadenomata, 
cystadenoma  proliferens,  polycystoma,  cystic  fibroma,  tubular  adenoma,  etc. 


526 


THE    CHEST 


border-line  of  malignancy.  Ordinarily,  it  suffices  to  remove  them  by 
a  small  local  incision,  but  the  histology  of  each  tumor  must  be  studied 
carefully,  for  there  is  always  a  possibility  of  its  developing  late  into 
carcinoma. 

Papillary  cystadenomata  constitute  the  second  group  of  fibro-epi- 
thelial  tumors.  They  are  not  common,  but  have  distinct  clinical  and 
histologic  characteristics.  J.ike  the  periductal  sarcomata,  they  occur 
commonly  in  midtUe-aged  married  women;  they  are  of  slow  growth 
and  long  duration,  antl  while  not  very  troublesome  and  causing  little 
pain,  their  characteristic  symptom  is  the  discharge  of  a  bloody  fluid 

A**     ■■'■J 


'/0  \ 


Fig.  338. — Diffuse  mammary  hypertrophy  and  prejinancy  (Massachusetts  General 

Hospital). 

from  the  nipple.  In  consistency  they  are  hard  usually,  though  occasion- 
ally one  may  detect  fluctuation;  rarely  is  there  involvement  of  the  skin 
and  axillary  nodes.  This  timior  is  most  often  foimd  close  beneath  the 
nipple.  If  you  examine  the  excised  specimen,  you  will  find,  on  section, 
a  cyst  cavity  containing  a  bloody  fluid,  the  walls  of  the  cj'st  lined  with 
papillary  or  villous  outgrowths  composed  of  connective  tissue  sur- 
rounded abundantly  by  epithelium  of  the  ductal  rather  than  the  acinal 
cells. 

In  the  case  of  small  papillaiy  cystadenomata,  I'esection  generally 
suffices  for  a  cure,  but  when  the  tumor  is  of  considerable  size,  of  long 


OTHER    BUKAST   TUMORS  527 

Standing,  and  cspecialiv  if  the  axilla  be  involved,  one  should  do  a  total 
dissection  of  the  breast  and  axilla.  Such  operations  give  every  hope  of  a 
pornianent  cure,  but  the  surgeon  should  remember  that  tumors  of  this 
type  frequently  become  malignant  when  left  untreated. 

There  is  another  class  of  benign  breast  enlargements  which  should 
not  properly  be  grouped  with  the  neoplasms  I  have  just  described,  i 
mean  those  diffuse  enlargements  of  the  breast  to  which  we  apply  the 
term  "  hyperplasia."  This  term  signifies  an  increase  m  both  the  fibrous 
and  epithelial  elements,  and  may  affect  one  or  many  lobules.  ^  arren 
divides  "  hyperplasia"  into  two  divisions:  (1)  Diffuse  hypertrophy  and 
(2)  abnormal  involution.^ 


Fig.  339.— Plastic  resection  of  the  breast,  line  of  incision— step  1. 

Diffuse  hypertrophy  is  a  rare  condition  which  may  be  found  in 
women  of  all  ages,  especially  before  the  menopause.  One  or  both  breasts 
may  be  affected,  and  the  growths  may  reach  an  enormous  size,  so  that 
their  amputation  to  relieve  the  patient  of  their  weight  may  be  neces- 

^^"^  Abnormal  involution  (senile  parenchymatous  hypertrophjO  is  a 
more  common  and  more  serious  matter,  and  the  important  fact  about  it 
to  be  borne  in  mind  is  that  it  has  a  benign  and  a  malignant  stap.  V\  hen 
it  is  found  in  the  malignant  stage,  it  must  be  treated  by  radical  operation. 
In  the  benign  stage,  however,  one  finds  two  types  of  senile  hypertrophy, 

1  This  is  the  condition  admirably  described  by  Bloodgood  under  the  term  "senile 
,  ,  ,       „^^^r,u^r  "      Thin  iq  the  chronic  mterstitial  mastitis  oi   zim 

parenchymatous  hypertrophy.         ilns  is  y?5./^™  V,,  .  x,       j^j-onic  mastitis  or 
Fnalish  writers-  the  chronic  cirrhosmg  mastitis  of  Billroth,  tne  cnromc  "3'^*^., 
jKefibr"  adenoma  of  Wood;  the  cystic  d^ease  of  the  breast  of  Bryant,  the  fibrous 
hyperplasia  with  retention  cysts  of  W.  F.  ^^  hitney  etat. 


528 


THE   CHEST 


the  cystic  and  the  adenocystic.  In  the  cystic  type  the  fibrous  thickening 
has  produced  dilatation  of  the  ducts  alone.  In  the  adenocystic  tyj^e  the 
cysts  are  present  also,  but  in  addition  there  are  proliferative  changes  in 
their  epithelium. 

Women  in  middle  or  advanced  life  are  the  subjects  of  abnormal  in- 
volution. In  many  cases  of  both  the  cystic  and  adenocystic  forms,  both 
breasts  are  involved,  though  usually  to  a  different  degree,  and  the 
masses  may  present  diffu.se  or  local  hardenings.  A  hardening  may  bo 
firm  and  nodular,  or  soft  and  even  fluctuant.  In  a  great  many  cases 
there  are  pain  and  tenderness;  in  a  few  there  are  enlarged  axillary 
nodes;  frequently  there  is  inversion  of  the  nipple.     In  most  cases  the 


Fig.  3-40. — Plastic  resection  of  the  breast — step  2.     Breast  turned  over  and  tumor 
exposed  by  triangular  incision. 


process  is  diffuse;  rarely  one  lobule  of  the  gland  alone  is  affected,  sug- 
gesting an  encapsulated  tumor.  The  microscope  shows  fibrous  hyper- 
plasia and  secondary  involvement  of  the  gland  stiiicture,  with  cyst 
formation.  In  the  adenocystic  type  of  abnormal  involution  one  may 
distinguish  three  groups,  depending  on  the  character  or  degree  of  the 
epithelial  growth,  as  follows:  (1)  Proliferation  of  the  acini;  (2)  papillary 
outgrowths  of  epithelium  into  cysts,  and  (3)  adenomatous  proliferation 
of  epithelium.  The  first  and  second  of  these  may  possibly  develop  into 
carcinoma,  while  adenomatous  proliferation  is  especially  interesting, 
from  the  fact  that  in  its  presence  chiefly  we  find  the  combination  of  invo- 
lution and  cancer.  The  reader  will  see.  therefore,  that  these  cases  of 
senile  hypertrophy  are  of  striking  and  anxious  importance.     At  first,  on 


MASTITIS  529 

examininfr  thorn,  no  man  can  say  whether  or  not  they  are  mahgnant. 
For  this  reason,  whenever  one  finds  induration  in  the  breast  of  a  woman 
at  the  menopause  or  later,  he  should  operate.  He  may  do  a  plastic 
resection  and  remove  the  growth  for  immediate  examination,  and  he  maj' 
do  a  complete  radical  operation  if  it  seems  indicated. 

The  operation  of  phistic  resection  is  simple,  easy,  and  causes  little  or 
no  disfigurement.  The  surgeon  enters  his  knife  at  the  periphery  of 
the  breast  high  in  the  anterior  axillary  line,  and  sweeps  it  down  around 
the  breast  so  as  to  take  in  one-half  to  two-thirds  of  the  gland's  circum- 
ference. He  then  dissects  rapidly  down  to  the  aponeurosis  of  the 
underlying  muscle  and  turns  the  breast  up,  when  he  may  attack  from 
below  and  remove  tumors  and  other  suspicious  thickenings,  as  I  have 
indicated  in  the  accompanying  figures  adapted  from  Warren's  paper. 


Fig.  341. — Plastic  resection  of  the  breast — step  3. 

After  excising  the  masses  he  closes  with  buried  absorbable  stitches 
the  gap  in  the  gland  and  replaces  the  breast ;  or,  if  necessary,  he  may 
proceed  to  the  complete  radical  operation.  The  wound  heals  rapidly 
and  kindly  and  a  slight  scar  only  remains.  The  simple  plastic  resection 
may  be  dressed  with  an  empire  bandage,  and  the  convalescence  should 
not  last  more  than  ten  days.  So  much  for  our  discussion  of  tumors  of 
the  breast,  malignant  and  benign. 

MASTITIS 

Acute  mastitis  with  abscess  is  that  affection  of  the  breast  gland 
which  next,  after  cancer,  is  most  interesting  to  the  physician,  but  as 

.34 


530  THE   CHEST 

this  is  a  disease  which  concerns  obstetricians  especially,  wo  need  say 
little  of  it  here.  It  is  an  inllaniniation  of  the  nipj)le  and  breast  ducts 
and  is  due  directly  to  an  infection  in  nursing  women.  One  wonders 
perhaps  that  all  women  during  lactation  do  not  suffer  from  acute  mas- 
titis. The  essentials  for  the  setting  up  of  such  an  inflammation  are  some 
slight  crack  or  al^rasion  in  the  nipple,  giving  lodgment  to  infecting  or- 
ganisms, and  a  milk-]:)r()ducing  breast  which  is  imperfectly  drained. 
Nurses  speak  of  "caked  breasts,"  by  which  we  understand  a  backing  up 
and  stagnation  of  milk  in  the  acini  and  ducts.  If  infecting  bacteria 
reach  these  deeper  parts,  they  set  up  readily  an  irritation  to  which  the 
organism  responds  with  the  production  of  hyperemia,  inflammation,  and 
pus;  as  the  infection  progresses  the  breast  elements  break  down,  and 
shortly  there  is  produced  a  considerable  area  of  suppuration;  indeed, 
the  whole  breast  may  become  involved.  When  one  examines  a  woman 
suffering  from  breast  abscess,  he  finds  her  more  or  less  prostrated  with 
fever,  with  a  rapid  pulse  and  great  pain  in  the  breast,  which  looks  dis- 
tended, red,  and  glossy,  varying  in  consistency,  in  one  place  exquisitely 
tender  and  fluctuant,  elsewhere  less  tender,  but  hard  and  brawny. 

The  treatment  of  such  infected  breasts  consists  in  stopping  the  in- 
fant's nursing,  supporting  the  breast  in  a  firm  bandage  with  an  ice-cap, 
and,  in  the  early  stages,  applying  massage  to  evacuate  the  milk.  At  the 
same  time  copious  movements  of  the  bowels  should  be  obtained  by  the 
use  of  salts.  When  an  abscess  has  formed,  it  should  be  opened  thor- 
oughly by  incisions  radiating  outward  from  the  nipple,  but  the  cut 
should  not  involve  the  areola.  This  operation  frequently  leaves  a  badly 
scarred  and  deformed  breast.  Another  method  of  operating — a  method 
effective  and  less  deforming,  is  to  turn  up  the  breast  from  below,  as  in 
the  plastic  resection  operation.  The  abscess  may  then  be  opened  at 
its  base  and  drained  after  the  breast  has  been  replaced  in  position. 
Throughout  the  patient's  convalescence  the  breast  should  be  supported 
by  comfortable  bandages,  and  the  abscess  cavity  should  be  irrigated 
daily.  These  patients,  like  so  many  others  afflicted  with  local  infec- 
tions, may  be  helped  greatly  by  appropriate  opsonic  injections. 

Chronic  infections  of  the  breast  are  far  less  frequent  than  the 
acute  infections,  and  may  be  divided  into  two  classes — infections  con- 
nected with  lactation,  and  such  specific  infections  as  those  due  to  the 
organisms  of  tuberculosis  and  syphilis.  The  much-abused  term  "chronic 
mastitis  "  should  be  applied  to  the  lactation  inflammation  only.  Chronic 
mastitis  may  be  found  in  women  toward  the  end  of  lactation,  and  appears 
as  small  multiple  abscesses  and  necrotic  foci  distributed  in  close  relation 
with  the  deeper  ducts  throughout  the  breast.  These  foci  appear  as 
tender,  indurated  masses  and  may  be  adherent  to  the  skin,  while  the 
axillary  nodes  may  be  enlarged.  There  is  an  increased  amount  of 
fibrous  tissue  also,  while  the  periductal  tissue  is  infiltrated  with  small 
round-cells  and  leukocytes.  The  striking  clinical  characteristic  is  an 
irregular,  extensive  induration  of  the  breast  occurring  shortly  after 
lactation  and  affecting  3'oung  mothers  especially.  Surgical  treatment 
alone  is  effective. 


MASTITIS  531 

Paget's  disease  of  the  nipple  (ni:ili<2;nant  dermatitis)  is  an  infection 
of  cl{)iil)tt'ul  (>ti()l{)gy  aiul  natur(>.  It  consists  in  a  chronic  inflammation 
of  the  epithehal  hxyer  of  the  nipple  and  areola.  It  occurs  usually  in 
women  beyond  middle  life,  and  frequently  advances  to  epithelioma  of 
the  nii)p]e  and  to  duct  cancer.  It  is  not  a  simple  eczema.  The  affected 
portion  appears  raw  and  red;  from  it  there  exudes  a  yellow  discharge, 
and  the  disease  may  extend  superficially  over  much  of  the  gland.  The 
axillary  region  becomes  affected.  When  the  surgeon  has  determined 
that  local  applications  are  useless,  he  should  proceed  with  the  knife 
thoroughly  to  extirpate  the  disease.  This  may  involve  radical  removal 
of  the  breast  with  dissection  of  the  axilla. 

By  galactocele  we  mean  a  breast  retention  cyst,  the  contents  of 
which  are  of  a  milky  character.  If  these  cysts  do  not  become  infected, 
the  harmless,  neutral,  milky  fluid  may  remain  indefinitely.  Frequently 
one  may  relieve  the  patient  by  aspirating  the  cyst  and  strapping  the 
breast. 

The  important  specific  inflammations  of  the  breast  are  due  to  tuber- 
culosis, actinomycosis,  and  syphilis. 

Tuberculous  disease  of  the  breast  is  rare,  and  more  rare  in  men 
than  in  women.  The  victims  are  usually  between  fifteen  and  thirty 
years  of  age,  and  are  wont  to  show  evidence  of  tuberculosis  elsewhere. 
The  disease  manifests  itself  variously — sometimes  as  a  cold  abscess  in 
the  breast;  sometimes  there  are  isolated  caseous  nodules,  and  this 
form  is  the  most  common ;  sometimes  the  disease  starts  as  an  ulceration  in 
the  region  of  the  nipple.  The  cold  abscess  may  remain  indefinitely; 
caseous  nodules  may  break  down  and  cause  ulceration,  with  the  form- 
ation of  sinuses;  superficial  ulceration  may  spread,  while  in  all  forms 
the  axillary  nodes  may  be  affected. 

If  the  patient's  condition  is  fair  and  extensive  tuberculosis  be  not 
present  elsewhere,  the  surgeon  should  amputate  the  breast  and  remove 
thoroughly  all  suspicious  foci. 

A  few  cases  of  actinomycosis  of  the  breast  have  been  reported. 
Like  actinomycosis  elsewhere,  this  is  a  chronic  destructive  process  which 
goes  on  burrowing,  forming  abscesses  and  sinuses.  To  establish  the 
diagnosis  one  must  discover  the  characteristic  fungus  in  the  discharges. 
Total  removal  of  the  breast  generally  will  destroy  the  disease,  and  prom- 
ising results  have  been  obtained  by  the  use  of  copper  salts  after  Bevan's 
fashion,  which  I  described  in  dealing  with  abdominal  actinomycosis. 

Manifestations  of  syphilis  of  the  breast  are  extremely  rare  and  occur 
as  gummatous  mastitis  late  in  the  course  of  a  syphilis.  The  lesions  are 
circumscribed  and  may  suggest  cancer  to  the  examiner.  So  uncommon 
is  the  condition  that  the  true  diagnosis  probably  will  not  occur  to  the 
surgeon.  However,  if  syphilis  is  suspected,  he  should  prescribe  anti- 
syphilitic  remedies,  and  give  them  a  trial  for  at  least  three  weeks  be- 
fore attempting  any  operation.  Should  the  diagnosis  of  syphilis  be 
confirmed,  he  should  do  no  operation. 

Echinococcus  of  the  mammary  gland  is  uncommon;  it  should  be 
treated  by  incision  and  removal  of  the  sac-wall. 


532  THE    CHEST 

Besides  such  inflammatory  diseases,  there  are  a  few  additional  breast 
lesions  which  deserve  mention. 

RETENTION   CYSTS 

Single  retention  cysts  occasionall}-  are  found  in  the  breast,  and  are  of 
the  same  general  character  as  those  produced  by  the  occlusion  of  a  duct 
in  other  glandular  structures.  These  cysts  occur  at  any  age  after  the 
development  of  the  breast,  and  appear  as  isolated,  painless,  clastic, 
fluctuant  tumors,  in  size  varying  from  a  walnut  to  a  hen's  egg,  and  of 
uniform  and  rapid  growth.  They  should  be  enucleated  either  through 
a  direct  incision  or  by  plastic  resection. 

Authors  mention  sundry  other  tumors  of  the  breast  which  are  desig- 
nated non-indigenous — that  is  to  say,  they  are  situated  in  the  breast 
accidentally,  as  it  were,  and  have  no  special  relation  to  the  peculiar 
mammary  gland  structure  as  regards  their  origin.  Such  tumors  are 
lipomata,  lymphangiomata,  enchondromata,  and  certain  rare  fibromata 
and  sarcomata.  Their  treatment  differs  in  no  wise  from  that  of  similar 
tumors  found  elsewhere. 

SUPERNUMERARY  BREASTS  AND  NIPPLES 

Supernumerary  breasts  and  nipples  occasionally  are  seen,  but  as 
they  have  no  special  tendenc}'  to  disease,  they  deserve  no  special  mention 
except  that  they  are  found  in  that  so-called  "milk  line''  extending 
from  the  clavicle  to  the  groin. 

One  sees,  therefore,  that  diseases  of  the  breast  are  various  and 
interesting.  No  other  single  gland  in  the  body  is  of  equal  surgical  im- 
portance; and  upon  it  the  activities  of  pathologists  have  concentrated 
themselves  until  study  of  the  breast  has  become  almost  a  specialty  in 
itself. 


PART  V 

THE  FACE  AND  NECK 


CHAPTER  XX 

HARELIP  AND  CLEFT-PALATE 

We  now  come  to  the  consideration  of  another  ancient  field  of  surgery. 
The  earliest  of  medical  writings  describe  superficial  congenital  abnor- 
malities, and  such  abnormalities  have  been  made  the  study  of  surgeons 
since  remote  times,  with  the  result  that  an  enormous  literature  upon 
the  subject  has  been  compiled.  Yet  it  is  within  the  last  one  hundred 
and  fifty  years  only  that  satisfactory  explanations  of,  and  operations 
for,  these  lesions  have  been  formulated.     A  variety  of  clefts  and  mal- 


Fio;.  3-' 2. — Single  harelip  and  cleft-palate. 


Fig.  343.— Double  harelip. 


formations  of  the  face  are  described,  but  most  of  them  are  rare,  nor, 
with  the  exception  of  harelip  and  cleft-palate,  do  they  come  within  the 
e very-day  experience  of  practitioners.  All  these  cleft  formations 
result  from  an  arrest  or  disturbance  of  development  in  early  fetal  life, 
as  a  glance  at  the  face  of  a  month-old  embryo  will  show.  We  are  apt  to 
think  of  deformed  lips  as  the  only  types  of  cleft  to  be  considered,  but 
surgical  literature  and  every  anatomic  museum  demonstrate  extensive 
clefts  and  deformities  not  only  of  the  lips,  but  of  the  nose,  cheeks,  fore- 

.=S33 


534 


THE    FACE    AND    NECK 


head,  eyes,  and  ears.  It  is  needless  here  to  detail  the  curiosities.  Fre- 
quently they  can  be  repaired  and  improved,  and  1  refer  the  student  to 
larger  works  on  the  subject  for  a  discussion  of  their  characteristics  and 
treatment. 

HARELIP 

Hureli}),  however,  is  a  coninion  deformity,  and  has  been  dealt  with 
by  such  distinguished  writers  as  Lemonier  (1776),  Eustache  (1779), 
John  C.  Warren  (1S20),  and  in  more  recent  times  by  von  Graefe,  Roux, 
G.  V.  I.  Brown,  J,  Collins  ^^'arrcn.  and  numerous  others.  The  lower  lip 
rarely  is  cleft;  the  vast  majority  of  clefts  are  found  in  the  upper  lip,  and 
these  clefts  or  harelips  are  of  three  main  varieties:  (1)  A  notch  in  the 
vermilion  border;  (2)  a  deep  notch  extending  nearly  to  the  nares;  (3)  a 
cleft  dividing  completely  the  upper  lip  and  penetrating  the  nasal  canal. 
Harelip  of  all  varieties  may  be  single  or  double,  and  single  harelip  is 


^:::^E:=> 


Fig.  344. — Double  harelip  and  cleft-palate. 


Fig.  345. — One-month  embryo 
(magnified). 


more  common  on  the  left  side  than  on  the  right.  All  forms  of  harelip 
— especially  complete  clefts  into  the  nares  and  double  harelip — may  be 
associated  with  cleft-palate,  but  we  are  considering  here  harelip  only. 
Double  harelip  may  present  two  simple  fissures  into  the  nostrils,  with  a 
bit  of  normal  looking  jaw  and  lip  between  them  (a  normally  placed  in- 
termaxillary bone)  or  the  intermaxillary  bone  may  be  thrust  foi-U'ard 
prominently  so  as  almost  to  resemble  a  small  proboscis  protruding 
beneath  the  nose — a  type  of  deformity  in  the  highest  degree  disgusting 
and  unsightly,  and  the  physician  who  has  the  misfortune  to  attend  in 
confinement  a  woman  giving  birth  to  an  infant  thus  marked  will  never 
forget  his  ovm.  distress  and  peiplexity  on  seeing  the  child's  face,  and  the 
horror  and  shock  of  the  parents. 

The  diagnosis  of  harelip  is  instantly  obvious,  but  the  symptoms 
and  the  disturbance  to  the  infant  develop  gradually.     Suckling  is  diffi- 


HARK  LIP  "  535 

cult  or  impossible;  mouth-breathing  is  the  rule,  with  an  inevitable  foul- 
ing of  the  buccal  and  nasal  cavities  and  an  occasional  consequent  bron- 
chitis or  pneumonia.  These  infants  fail  to  get  proper  nourishment  unless 
they  have  special  care.  As  a  result  of  such  disadvantages  harelip  babies 
arc  proverbially  feeble  and  rachitic — a  condition  not  due  necessarily  to 
an  inherent  weakness  or  taint,  but  to  lack  of  sufficient  and  proper  food. 
The  treatment  of  harelip  divides  itself,  therefore,  into  two  parts — 
the  feeding  and  sustaining  of  the  infant  and  the  repair  of  the  deformity.' 
If  the  attending  physician  is  not  skilled  in  the  problems  of  infant-feed- 
ing, he  should  consult  an  infant's  specialist  immediately  after  the  baby's 
birth.  Proper  treatment  consists  in  supplying  the  child  with  a  normal 
amount  of  an  accurately  prepared  cream  mixture,  plenty  of  water  to 
drink,  keeping  the  bowels  properly  open,  cleansing  the  mouth  thoroughly 
after  each  feeding,  and  feeding  by  means  of  a  dropper,  while  the  child  is 


Fig.  346. — Simplest  form  of  liarelip.  Fig.  347. — Single  notch  of  lip. 

held  in  the  semiprone  position.     I  believe  in  giving  a  little  brandy  as  a 
stimulant  for  a  week  before  operating. 

The  time  for  operating  on  harelip  is  in  the  sixth  or  seventh  week  of 
life,  as  a  rule.  By  this  time  the  baby  will  have  begun  to  react  well  after 
birth  and  to  flourish,  its  digestive  processes  and  heart  and  lung  action 
being  ready  for  the  strain  of  the  operation.  I  regard  ether  as  a  safe  and 
satisfactory  anesthetic.  There  is  no  need  of  keeping  the  child  constantly 
under  its  influence  during  the  operation,  but  one  may  allow  the  patient 
partially  to  come  out  from  the  anesthetic  and  to  cry  from  time  to  time. 
The  air-passages  are  thus  cleared  and  the  surgeon  feels  reassured. 
The  child,  tighth-  swathed  in  a  sheet,  should  be  held  upright  in  the  arms 
of  an  attendant,  behind  whose  shoulder  stands  the  etherizer  with  his 
cone,  while  the  surgeon  sits  in  front  of  the  patient.  The  tj^es  of  hare- 
lip operations  are  many,  but  the  good  operations  are  all  much  of  a 
kind.     In  a  word,  a  good   harelip   operation  involves  loosening  with 

1  J.  G.  Mumford,  Medical  and  Surgical  Treatment  of  Harelip,  Boston  Med.  and 
Surg.  Jour.,  March  3,  1S98. 


536 


THE    FACE    AXD    NECK 


blunt-pointed  scissors  the  cheek  from  the  upper  jaw,  so  as  to  dimin- 
ish subsequent  traction,  carefully  trimming  and  adjusting  with  the 
knife  the  wound-edges  to  be  sewed  and  everting  downward  a  mar- 
ginal flap  so  as  to  obviate  the  puckered  notch  which  comes  with 
the  contracting  scar  of  a  badly  done  operation.  There  is  a  familiar 
and  abominable  operation,  which  consists  in  slashing  with  scissors  the 


Fig.  348. — Infant  hold  in  position  for  harelip  operation. 

edges  of  the  cleft,  so  as  to  transform  it  into  a  raw  inverted  V,  and 
sewing  it  up  with  through-and-through  stitches.  Invariably  there 
results  an  ugly  notched  lip.  The  text-books  tell  of  the  operations  of 
Nelaton,  Malgaigne,  Mirault,  von  Langenbeck,  Simon,  and  a  dozen 
others.  Nelaton's  operation  is  applied  to  single  notches.  The  required 
cuts  are  made  through  the  lip  above  the  notch  with  no  sacrifice  of  tissue. 


HARELIP  537 

When  the  ends  of  the  cuts  are  brought  together  the  notch  is  converted 
into  a  nipple,  the  principle  of  the  operation  being  similar  to  that  of  the 
Heineke-Mikulicz  pyloroplasty.  If  the  cleft  in  the  lip  be  single  and 
reach  nearly  to  the  nostril,  it  is  necessary  to  sacrifice  some  tissue.  But 
names  and  descriptions  count  for  little;  the  accompanying  diagrams 
show  best  how  these  operations  may  be  done. 

Double  harelip  is  far  more  difficult  to  close  successfully  and  properly 
than  is  the  single  harelip.  The  following  description  of  the  technic 
with  modifications  may  be  applied  to  harelip  operations  of  all  sorts, 
and  the  surgeon  should  remember  that  no  routine  fits  all  cases. 

How  shall  one  dispose  of  the  intermaxillary  bonef  If  the  bone  be 
not  greatly  displaced,  and  if  it  be  readily  pushed  back  and  held  in  posi- 
tion beneath  the  nasal  septum,  one  may  proceed  immediately  with  his 


Fig.  349. — Intermaxillary  bone. 

plastic  work.  Occasionally,  however,  the  intermaxillary  bone  cannot 
be  pushed  into  good  position,  and  upon  this  we  are  confronted  with  a 
conflict  of  authority.  Some  conservative  surgeons  assure  us  that  the 
intermaxillary  bone  must  be  preserved  at  all  costs,  either  by  fracturing 
it  and  crowding  it  down  or  by  sHcing  out  a  V-shaped  bit  from  the  vomer, 
and  thus  allowing  room  for  replacement  of  the  intermaxillary.  Other 
surgeons  excise  the  obtrusive  bone  from  its  mucocutaneous  envelop. 
They  point  out  that  the  intermaxillary  bone  is  useless  and  fails  to  develop 
when  crowded  back,  and  that  the  incisor  teeth  which  it  bears  are  mdi- 
mentary  and  short  lived.  When  the  bone  is  removed,  a  gap  is  left  in  the 
alveolar  line  which  must  be  filled  by  a  plate  or  other  dental  apparatus. 
I  advise  removing  troublesome  intermaxillaries.  Then  in  detail  one 
may  proceed  as  follows:  an  assistant  on  either  side  seizes  the  edges  of 
the  lip  and  holds  them  forward,  at  the  same  time  controlling  hemor- 


538 


THE   KACE  AND  NECK 


rhage  by  pressure.  The  surgeon,  using  blunt-pointed  scissors,  then  dis- 
sects up  the  cheek  on  either  side  of  the  alac  of  the  nose,  hugging  closely 
the  bone,  so  as  to  avoid  hemorrhage.     He  then  refreshes  the  edges  of 


Fig.  350. — Looseniiii?  the  clicck. 


mucosa  about  the  intermaxillary,  working  with  a  small  sharp-pointed 
knife;  he  trims  off  the  edges  of  the  larger  flaps,  leaving  at  either  angle 
tabs  which  may  be  brought  dow'n  and  out  to  form  the  required  nipple- 


Fig.  3.51. — Drop  silver  stitch. 


Fig.   3.52. 


-Final   suporficial  stitoli 
place. 


like  projection  which  shall  preserve  properly  the  line  of  the  up])er  lij). 
He  places  one  deep  and  important  stitch  high,  jnissing  from  sulcus  to 
sulcus  of  the  alaj  nasi.    Remember  that  the  nostrils  generally  are  flattened 


HARELIP  5.39 

by  the  existiufi;  deformity,  and  lliat  this  deeply  placed  stitch,  preferably 
of  siKcr  and  sliollcd,  acts  as  a  strong  stay  to  hold  closely  th(!  wide  margin 
of  the  wound  and  to  build  up  properly  the  ala>  and  tip  of  the  nose.  The 
placing  of  this  deep  silver  stitch  is  somewhat  difficult  and  is  important. 
The  rest  of  the  operation  is  now  easy  and  obvious.  I  complete  the  sew- 
ing up,  using  silk  sutures  thi'eaded  at  either  end  into  fine  round  cambric 
needles.  These  sutures  do  not  take  in  the  skin,  liut  are  passed  through 
the  subcutaneous  tissues  and  mucosa  from  without  inward,  and  are  tied 
inside  the  mouth,  the  ends  being  left  long.  Practically  this  completes 
the  operation;  but  if  a  slight  gaphig  skin-line  remains,  one  may  close  it 
with  a  few  superficial  intestinal  stitches  to  be  removed  on  the  third 
day.  Stitch  abscess  and  ugly  scars  are  obviated  by  this  method  of 
sewing.  By  no  means  the  least  important  part  of  the  operation  is  the 
dressing  of  the  wound,  which  implies  a  supporting  strap  from  cheek  to 
cheek  to  take  off  traction  from  the  line  of  incision.  I  use  commonly  a 
crepe  de  lisse  butterfly,  drawn  tightly  and  fastened  with  collodion. 


"^^ 


Fig.  353. — Sketch  showing  dressing  completed. 

Taylor^  recommends  the  device  shown  in  the  illustration.     It  seems 
reasonable  and  useful. 

The  after-care  of  these  cases  is  delicate  and  Important.  The  opera- 
tion causes  a  certain  amount  of  shock,  and  the  baby  swallows  a  certain 
amount  of  blood.  As  a  result  there  is  usually  some  gastro-intestinal 
disturbance  and  imperfect  assimilation  of  food  for  a  time;  so  the  after- 
care resolves  itself  into  general  treatment  and  special  dressings  of  the 
wounded  mouth.  Six  hours  after  the  operation  give  the  baby  a  dram 
of  olive  oil  to  clear  out  the  bowels,  and  begin  carefully  with  artificial 
feeding.  After  each  feeding  the  mouth,  tongue,  lips,  and  nostrils  should 
be  wiped  out  thoroughly  with  a  cotton  stick  dipped  in  boric  acid  (4  per 
cent.).  All  these  operations  are  necessarily  somewhat  septic,  so  that 
one  cannot  expect  perfect  primary  union  in  ever}^  case,  but  the  lips  of 
healthy  children  heal  quite  readily,  and  even  if  there  be  some  gaping  of 
the  upper  part  of  the  wound  beneath  the  nose,  the  lower  part  and  ver- 

^  Alfred  S.  Taylor,  A  Dressing  after  Harelip  Operation,  Jour.  Amer.  Med.  Assoc, 
vol.  xlvii. 


540  THE    FACE    AND    NECK 

milion  border  ncarl}'  ahvays  hold.  If  the  veiniilion  border  alone  re- 
mains sound,  one  is  justified  in  looking  for  eventual  healing  by  second 
intention,  and  this  is  aided  by  careful  strapping.  By  the  end  of  two 
weeks  the  union  should  be  so  sound  that  all  apparatus  may  be  discarded. 


Fipj.   354. — Taylor's  dressing  complfted. 

If  harelip  operations  be  done  properly  and  deftly,  the  improvement 
in  the  infant's  appearance  is  remarkable,  and  few  operations  upon  chil- 
dren gain  so  instantly  the  enthusiastic  gratitude  of  parents. 

CLEFT-PALATE 

Cleft-palate  often  is  associated  with  harelip,  and  demands  our  study 
in  connection  with  it.  A  cleft  may  divide  the  soft  palate  only  or  may 
penetrate  through  the  bony  palate  to  the  opening  of  the  nostrils;  and 
when  the  bony  palate  is  cleft,  the  soft  palate  is  always  involved.  Some- 
times the  cleft  may  be  at  one  side,  passing  either  to  the  right  or  left  of  the 
vomer,  but  more  commonly  the  opening  is  in  the  middle  line,  with  the 
vomer  hanging  free  above  it.  Other  peculiarities  in  the  formation  of 
the  upper  jaw  are  associated  with  cleft  palate.  The  arch  of  the  palate 
is  abnormally  high,  so  that  the  palate  appears  like  a  high-pitched  roof 
when  looked  at  from  below — the  cleft  being  substituted  for  the  ridge 
pole,  while  the  cavities  of  the  nose  and  mouth  form  a  continuous  whole. 
These    skeletal   imperfections   are   generally   associated   with   harelip, 


CLEFT-PALATE  541 

though  harch'p  alone,  without  cleft-palate,  is  common  enough.  I  have 
noted  the  functional  (.listurbances  resulting  from  harelip,  and  one  sees 
at  once  how  much  more  serious  must  be  the  disturbances  when  cleft- 
palate  is  added  to  harelip.  Suckling  is  impossible,  and  malnutrition  is 
a  common  result.  As  the  child  grows  the  lack  of  proper  incisor  teeth 
is  a  disadvantage,  while  serious  defects  of  speech  develop  later — defects 
which  can  never  be  overcome  through  operation  or  apparatus  when  once 
the  bad  habits  are  formed.  Moreover,  with  the  cleft  open,  particles  of 
food  become  lodged  in  the  nares  and  set  up  troublesome  or  foul  catarrhs 
and  spreading  infections.  One  sees  then  the  imperative  need  of  treat- 
ment. 

Treatment. — Not  long  ago  there  were  two  vigorously  opposed 
opinions  on  this  subject.  Some  men  claimed  the  greatest  benefit  from 
obturators — plates  devised  by  dentists  for  filling  in  the  clefts  in  the  hard 
and  soft  palates.  Other  men  protested  that  the  deformity  could  be 
repaired  properly  by  operation.  It  is  needless  here  to  discuss  the  merits 
of  this  rather  ancient  controversy  further  than  to  state  that  although 
obturators  have  been  of  undoubted  benefit  in  many  cases,  especially 
in  adult  cases,  still  to-day  improvements  in  technic  have  convinced 
surgeons  that  an  operation  is  best  for  young  and  vigorous  patients. 
In  spite  of  our  confidence  and  conviction,  however,  one  cannot  be  cer- 
tain always  of  obtaining  satisfactory  speech  or  perfect  cosmetic  results. 
The  cases  are  not  numerous  in  the  hands  of  any  one  man,  but  there  are  a 
few  dental  surgeons,  in  this  country  especially,  who  have  greatly  im- 
proved the  operation. 

Students  of  the  subject  recognize  that  the  association  of  harelip  and 
cleft-palate  necessitates  the  treatment  of  both  conditions  as  a  patho- 
logic unit,  bearing  in  mind  always  that  the  deformity  is  evidence  of 
developmental  failure  in  utero,  and  that  these  children  must  be  regarded 
as  degenerates  with  unstable  nervous  systems.  For  this  reason,  if  for 
no  other,  the  surgeon  should  take  every  precaution  to  prevent  shock, 
and  should  operate  at  as  late  a  time  as  possible  consistent  with  the 
preservation  of  the  speech  function. 

In  these  cases  then,  and  in  simple  harelip  cases  as  well,  one  should 
begin,  as  soon  as  the  child  is  bom,  by  gentle  means  to  draw  together  the 
parts.  Assuming  that  a  competent  surgeon  has  in  charge  the  child  from 
its  birth  until  the  entire  deformity  is  remedied,  he  should  apply  at  once 
and  have  reapplied  daily  from  cheek  to  cheek  a  strip  of  zinc  oxid  ad- 
hesive plaster.  This  bridges  the  labial  cleft,  hides  the  deformity,  brings 
nearer  together  gradually  both  soft  and  hard  parts, — for  the  palate  cleft 
can  be  narrowed  by  such  means, — and  prepares  them  the  better  for  sub- 
sequent operations.  Thiersch  favors  a  composite  strap — a  plaster — into 
the  middle  portion  of  which  is  set  an  elastic  band  to  lie  across  the  open- 
ing in  the  lip  and  the  protruding  intermaxillary.  The  elastic  insert 
exerts  a  constant  contracting  force  at  the  same  time  that  it  gradually 
crowds  back  the  intermaxillary.  For  the  first  six  weeks  the  surgeon 
should  take  every  pains  that  the  infant  be  properly  nourished  and  brought 
into  condition  for  operation.     Then  in  the  middle  of  the  second  month 


542 


THr<:    FACE    AND    XKCK 


he  should  repair  the  haroHp.  Kepair  of  the  cleft -])alate  should  not  be 
done  at  this  time  under  any  circumstances.  Some  operators  in  the  past 
have  advised  that  the  cleft-palate  be  repaired  first,  but  e\])erience  has 
shown  that  little  Is  gained  by  this  measure  as  compared  with  the  ad- 
vantages secured  by  restoring  first  the  lip.     l-'urtherniorc,  the  opera- 


Fig.    3.5.5. — Brown's   compression   apparatus. 

tion  for  cleft-palate  is  severe  and  the  infant  mortality  after  it  is  high. 
Besides  this,  cleft-palate  operations  on  young  babies  are  extremely 
difficult,  owing  to  the  delicacy  of  the  parts  with  which  the  surgeon  must 
deal. 


#■■'  i..i  t^ 


Fig.  356.  -  I-illchn. 


-u\'fr  ili-^c 


t'i;^.    3.57. — I'illchrown's    dissection     of 
j)alutal  mucosa. 


The  restored  lip  exerts  some  slight  compressing  action  upon  the 
divided  maxillary  bones,  but  this  is  not  by  any  means  enough,  so  that 
it  is  advisable  to  employ  some  more  effective  compression  apparatus 
for  the  six  months  preceding  operation  upon  the  palate.  So  long  as  the 
infant's  molar  teeth  remain  unerupted,  the  best  means  of  compression 


CLEKT-PALATE  543 

is  that  I  have  ah'oady  suggested,  b}^  a  strap  from  cheek  to  cheek  across 
the  Hp;  but  after  the  eruption  of  the  molar  teeth,  they  can  be  used  as 
bases  on  which  to  fix  a  contracting  screw/  This  device  exerts  traction 
so  effectively  that  In'  the  end  of  a  few  months  the  cleft  is  materially 
diminished  in  width,  and  by  so  much  is  the  operation  rendered  easier. 
AYhen  the  healthy  child  is  well  advanced  in  its  second  3'ear,  the  surgeon 
proceeds  to  the — 

Operation  for  Cleft-palate.— The  child  is  brought  to  the  end  of 
the  operating  table  and  the  head  is  depressed  in  the  position  of  Rose: 
the  mouth  is  held  open  by  a  strong,  well-fitting  gag,  and  the  whole  cavity 
with  the  nostrils  is  swabbed  out  thoroughly  with  70  per  cent,  alcohol, 
followed  by  boric  acid.  These  fluids  with  accumulating  blood  are  not 
swallowed  or  inhaled,  but  can  be  wiped  away  readily.  The  surgeon  had 
best  employ  ether  anesthesia,  which  may  be  administered  in  the  or- 
dinary fashion,  but  is  well  given  through  a  nasal  or  mouth  tube  after 
the  method  of  Crile  or  Fillebrown.-  The  surgeon  must  use  small  in- 
struments—knives, scissors,  vulsella,  catch-forceps,  periosteum  retrac- 
tors, and  elevator,  and  a  variety  of  curved  needles  with  a  needle-holder. 
Employ  for  sewing  up  fine  silver  wire  and  silk  sutures,  and  make  use  of 
small  silver  discs,  about  the  size  of  a  gold  dollar  cut  square,  as  supports 
for  the  quilted  stitches.  Following  Fillebrown,  in  closing  the  hard  palate 
cleft,  I  have  given  up  the  Langenbeck  method  of  splitting  away  the 
mucosa  parallel  with  and  close  to  the  alveolar  processes;  I  recommend 
the  following  procedure:  turn  back  from  the  cleft  on  either  side  and 
close  to  the  opening  an  abundant  flap  of  mucosa,  and  peel  it  off  from 
the  bone  nearly  to  the  alveolar  process.  Refresh  the  edges  of  the  flaps 
or,  preferably,  split  them  for  about  i  inch  in,  and  bring  thepi  together 
wdth  three  or  four  silver  stay  sutures  quilted  over  the  silver  discs. 
This  leaves  loose  flapping  edges,  which  may  be  joined  accurately, 
without  tension,  by  interrupted  silk  stitches.  Thus  one  has  completed 
the  repair  of  the  hard  palate,  while  the  two  halves  of  the  soft  palate 
remain  flapping. 

Frequently  it  is  well  to  postpone  for  a  time  the  operation  on  the  soft 
palate,  waiting  until  the  first  wound  has  healed  and  the  child  has  re- 
covered his  vigor. 

Repair  of  the  soft  palate  is  not  altogether  simple,  whether  the  cleft 
be  original  and  uncompHcated,  or  be  left  over  after  the  hard-palate  opera- 
tion. Earlier  operators  began  by  loosening  up  the  flaps,  cutting  the 
tensor  muscles  of  the  palate  and  the  pillars  of  the  fauces.  This^  is  a 
needlessly  mutilating  performance,  and  leaves  the  repaired  palate  m_  so 
functionless  a  condition  that  correct  speech  thereafter  is  almost  im- 
possible. To  relieve  the  tension  on  the  soft  palate  it  suffices  to  make 
lateral  incisions  external  to  the  tonsils,  and  to  dissect  up  the  tissues 

1  J.  D.  V.  Singlev,  Amer.  Med.,  Sept-ember  16,  1905. 

2  Fillebrown  described  his  apparatus  in  189.3:  it  is  on  the  plan  of  the  '  Junker 
system  "  It  consists  of  a  bellows,  a  wash-bottle  containing  ether,  and  a  tube  reach- 
ing to  the  patient's  mouth.  Air  is  blown  over  the  ether  in  the  bottle,  and  becoming 
charged  with  ether  vapor,  is  led  into  the  patient's  nares  or  mouth  by  means  ot  the 
tube. 


544  THE    FACE    AND    XKCK 

with  a  blunt  instrument,  so  as  to  avoid  hemorrhage.  Thus  one  forms 
lateral  buttonholes  which  relieve  sufficiently  tlie  tension.  The  flapping 
halves  of  the  soft  palate  may  then  be  refreshed  at  their  edges,  and 
brought  easil)^  together  with  interrupted  silk  sutures.  Then  the  mouth 
is  thoroughly  douched  and  wiped  out,  and  the  child  is  allowed  to  recover 
from  ether.  When  undertaking  one  of  these  cleft -palate  operations,  the 
surgeon  must  have  abundance  of  time — two  hours,  if  necessary — and 
the  patience  to  ])ick  his  way  along,  taking  each  step  slowl}-,  carefully, 
and  finally.  The  after-care  of  these  infants  and  children  is  important. 
Blood  has  been  lost,  and  it  is  well  to  assist  the  circulation  by  the  use  of 
salt  solution  enemata  until  the  patient  reacts  well.  Careful  feeding 
must  be  instituted,  and  the  child  watched  until  all  danger  has  passed. 
The  mouth  and  nares  must  be  wiped  out  several  times  a  day.  The  silver 
stitches  should  be  removed  on  the  eighth  day,  and  the  silk  stitches  two 
or  three  days  later.  If  all  goes  well,  healing  should  be  sound  in  two 
weeks. 

The  establishment  of  proper  speech  habits  is  difficult  in  all  cases. 
The  developing  children  should  be  put  under  the  care  of  a  competent 
teacher  if  possible.  When  these  operations  are  performed  on  half-grown 
children  or  on  adults,  one  may  expect  an  excellent  anatomic  result,  but 
good  speech  habits  cannot  be  expected.  For  years  after  the  operation 
children  should  be  under  the  frequent  inspection  of  a  dentist  and  a  throat 
specialist,  because  all  such  abnormalities  as  faulty  teeth,  nasal  spurs, 
deviated  septa,  and  the  like  add  to  the  physiologic  errors  and  must  be 
met  and  corrected. 

Shocking  as  is  the  deformity  of  a  harelip,  it  is  scarcely  more  re- 
pulsive than  numerous  other  lesions  of  the  face,  congenital  and  ac- 
quired, especially  the  deforming  and  often  grotesque  imperfections  of 
the  features.  The  unfortunate  victims  of  such  defects  are  always  ob- 
jects of  repulsion  on  first  sight,  and  the  reacting  mental  effect  upon  the 
individuals  themselves  is  often  permanent  and  distressing.  Frequently 
these  lesions  serve  as  a  grevious  handicap  in  life,  though  in  rare  instances 
one  sees  such  unfortunates  attain  positions  of  conspicuous  eminence. 
I  have  referred  to  the  various  unusual  clefts  and  fissures  of  the  cheeks, 
nose,  eyes,  and  other  regions,  and  the  reader  will  recall  a  famous  case  in 
fiction,  Victor  Hugo's  "  I'Homme  qui  Ris." 

PLASTIC  OPERATIONS   ON  THE  FACE 

The  remedy  for  these  defects  nearly  alwavs  involves  a  plastic  opera- 
tion, and  plastic  operations  on  the  face,  though  anatomically  satisfy- 
ing, since  healing  is  prompt  and  sound,  seldom  give  pleasing  cosmetic 
results.  The  patient  remains  something  of  a  monstrosity,  painful  to 
the  beholder.  Nasal  defects  especially  are  deforming,  and  the  remedy, 
whether  by  some  one  of  the  ingenious  plastics  or  by  a  false  nose,  is  never 
satisfactory.  These  nasal  defects  appear  as  a  partial  or  complete  loss 
of  substance  of  the  nose.  Rarely  the  condition  is  congenital;  but  syph- 
ilis is  a  common  acquired  cause;  sometimes  the  cause  is  tuberculosis,  or 


PLASTIC    OPERATIONS   ON   THE    EACE  545 

there  may  have  been  an  injury.  Operations  for  repair  consist  in  turning 
down  various  flaps  to  fill  in  the  vacancies.  Flaps  are  taken  from  the 
forehead,  the  cheeks,  and  the  side  of  the  nose,  as  illustrated  by  the 
accompanying  cuts.  The  cuts,  however,  give  one  little  notion  of  the 
end-results.  The  defects  may  be  closed  in,  the  patient  rendered  more 
comfortable,  and  his  visage  less  hideous,  but  the  resulting  scars  are 
extensive  and  extremely  ugly. 

Ectropion,  or  eversion  of  the  lower  eyehd,  is  not  uncommon,  and  may 
arise  from  a  burn,  ulcer,  or  injury.  There  are  various  operations  for 
its  relief,  which  certainly  improve  the  patient's  appearance.  Not  only 
this,  but  they  remedy  the  serious  distress  which  the  patient  suffers  from 
ectropion,  as  the  everted  lower  lid  continually  pours  out  tears. 


Fig.  358. — Method  of  rhinoplasty  (Linhart). 

Defects  in  the  cheeks  are  remedied  by  some  such  operation  as  that 
of  Schimmelbusch,  who  reflects  upward  a  flap  from  the  neck.  The 
neck  is  a  favorite  region,  when  suitable,  from  which  to  take  a  flap,  for 
the  cervical  skin  is  thin  and  elastic.  In  performing  all  these  plastic 
operations,  however,  one  should  take  pains  not  to  fill  in  a  normally 
hairless  area,  like  the  forehead  or  upper  portion  of  the  cheek,  with  a 
hairy  flap.  Cheeks  and  chins  extensively  scarred  by  bums  are  com- 
monly subjected  to  these  operations. 

Powder  face  is  a  frequent  misfortune,  and  is  due  to  a  close-range 
discharge  of  black  gun-powder,  which  forces  the  powder  grains  into  the 
skin.  If  the  patient  is  seen  at  once  before  the  grains  have  healed  in, 
most  of  the  particles  can  be  removed  by  vigorous  scrubbing  with  a  stiff 
nail-brush,  the  patient  being  under  ether.     After  the  grains  have  healed 

35 


546 


THE   FACE   AND    NECK 


nur^(.„-<L^ 


Fig.  360. — Codman's  rliinoplasty — incision  2. 

in,  however,  the  only  remedy  is  to  remove  the  particles  patiently,  by 
long-continued  picking  with  a  cataract  needle  or  the  point  of  a  knife. 


RANULA  547 

SALIVARY   FISTULA 

Salivary  fistula  results  from  wounds  or  disease  of  the  salivary  glands 
or  ducts,  and  is  a  troublesome  affliction,  though  not  particularly  de- 
forming. If  the  fistula  communicate  directly  with  the  gland,  it  will 
almost  always  heal,  provided  the  gland  be  not  diseased  and  the  normal 
channel  through  the  duct  remain  patent.  The  surgeon  may  rim  out 
such  a  fistula  with  the  cautery  and  apply  constant  compression,  or  he 
may  merely  bandage  the  lesion,  being  assured  that  eventually  it  will 
heal,  with  or  without  treatment. 

Fistula  from  the  ducts  is  a  more  serious  affair,  however,  and  Steno's 
duct  is  the  one  commonly  affected.  The  surgeon  should  look  for  and 
eliminate  any  underlying  cause  for  the  fistula.  I  have  seen  cases  of 
obstinate  fistula  due  to  tuberculosis  and  actinomycosis.  There  are 
various  operations  for  closing  fistulse  of  Steno's  duct,  and  these  opera- 
tions depend  upon  whether  or  not  the  distal  end  of  the  duct  in  the 
mouth  be  occluded.  If  the  distal  end  be  patent,  the  fistula  will  often 
heal  of  itself,  or  the  surgeon  may  dissect  out  the  duct  and  suture  the 
divided  ends.  Sometimes  it  is  necessary  to  open  through  the  mucous 
membrane  from  within  the  mouth,  to  find  the  central  end  of  the  duct, 
and  bring  it  out  into  the  buccal  cavity.  The  operation  of  de  Guise  is 
ingenious.  He  threads  a  piece  of  silk  through  two  needles  and  carries 
the  needles  through  the  cheek  into  the  mouth,  so  that  the  silk  will  em- 
brace a  bit  of  tissue  half  a  centimeter  in  length.  The  silk  is  tied  tightly 
within  the  mouth,  the  ends  are  cut  off,  and  the  margins  of  the  fistula 
at  the  surface  are  freshened  and  sutured. 

SALIVARY   STONES 

Occasionally  the  salts  cantained  in  saliva  are  deposited  as  a  calculus 
within  a  salivary  gland  or  its  duct.  Such  a  calculus  is  more  likely  to 
give  rise  to  swelling  than  to  pain,  so  that  a  salivary  cyst  may  result  from 
the  obstruction.  The  obvious  treatment  is  to  cut  down  upon  the  con- 
cretion, if  possible,  through  the  mouth,  and  remove  it. 

RANULA 

Ranula  is  the  name  given  to  a  cystic  tumor  situated  beneath  the 
tongue.  The  older  surgeons  described  it  as  a  retention  cyst  of  a  sali- 
vary gland  duct,  but  this  description  is  not  always  correct.  More 
commonly,  it  is  due  to  obstruction  in  the  duct  of  one  of  the  glands  of 
Bochdalek,  situated  in  the  floor  of  the  mouth,  near  the  frenum  of  the 
tongue.  There  may  be  multiple  cysts  on  either  side  of  the  tongue, 
but  commonly  the  growth  is  single.  Eanula  is  a  chronic  affair  as  us- 
ually seen,  though  acute  ranula  jnay  develop  suddenly  as  the  result  of 
irritation  of  a  small  cyst  hitherto  unnoticed.  A  ranula  sac  may  project 
entirely  beyond  the  floor  of  the  mouth,  and  push  up  the  tongue;  it  must 
be  difl'erentiated  from  a  distended  or  cystic  Wharton's  duct,  which  may 
dilate  greatly  and  press  downward  and  appear  beneath  the  chin.     It 


548  THH    1  ACK    AXI)    XKCK 

must  be  (listin<;uisho(l  from  tumoi-s  of  the  suhliiifiual  <ilan(l  itself  ai^v), 
from  lipoma  of  the  floor  of  the  mouth,  and  from  sublinjiual  dei'inoids,  all 
of  whieh  are  rai'e,  while  ramila  is  eommon  enough,  it  is  hy  no  means 
easy  to  cure  ranula,  and  one  of  the  faulty  operations  is  to  puneture  or 
dissect  off  the  superficial  portion  of  the  sac  and  to  cauterize  its  base. 
FrcHluently  this  proccnlure  fails.  The  only  final  and  satisfactory  method 
of  cure  is  by  complete  and  painstaking  dif^soction  of  the  sac.  In  some 
cases,  when  other  methods  have  failed,  it  may  be  necessary  to  ap])roach 
the  growth  through  the  chin  from  below,  and  so  to  remove  comjjletely 
the  whole  affected  gland  with  its  duct. 

THYROLINGUAL  OR  THYROGLOSSAL  CYSTS   AND   SINUSES 

Thyrolingual  or  thyroglossal  cysts  and  sinuses  are  extremely  inter- 
esting and  not  uncommon  conditions.  These  formations  result  from 
imperfect  closure  of  embryonic  clefts,  for  in  embryonal  life  the  thyroid 
gland  sends  a  duct  from  the  thyroid  isthmus  to  the  foramen  caecum  of 
the  dorsum  of  the  tongue.  Looked  at  from  above,  this  duct  is  found  in 
life  to  pass  from  the  base  of  the  tongue  down  the  middle  line  of  the 
neck,  to  be  connected  with  the  hyoid  body,  the  thyrohyoid  bursa,  and 
the  upper  portion  of  the  trachea  in  front,  where  it  divides  to  send  a 
branch  to  each  lateral  thyroitl  lobe.  So  the  duct  which  should  be  closed 
early  in  fetal  life,  generally  V)y  the  eighth  week,  may  persist  in  whole  or 
in  part.  It  may  in  part  develop  as  a  sublmgual  dermoid,  while  behind 
the  hyoid  bone  it  may  become  a  subhyoid  cyst.  Moreover,  that  portion 
of  the  duct  below  the  hyoid  may  develop  into  a  cyst  which  may  rupture 
and  establish  an  incomplete  cervical  fistula.  Should  the  whole  of  the 
sinus  remain  patent  ancl  a  cervical  fistula  become  established,  the  for- 
mation is  known  as  a  complete  cervical  fistula,  the  patency  of  which  is 
demonstrated  when  a  little  quinin  solution  is  injected  into  the  lower 
opening  and  the  patient  experiences  a  bitter  taste  in  the  mouth. 

The  treatment  of  these  cysts  and  sinuses  is  a  difficult  and  tedious 
matter,  and  consists  often  of  an  extensive  dissection.  A  general  anes- 
thetic is  obviously  necessary,  and  sometimes  one  must  perform  pre- 
liminary tracheotomy.  The  whole  track,  so  far  as  it  is  open,  must  be 
dissected  out,  especially  where  it  adheres  strongly  to  the  hyoid  bone, 
which  often  must  be  divided  and  retracted  in  order  to  get  at  the  cyst. 
Most  surgeons  have  had  the  trying  experience  of  operating  four  or  five 
times  on  a  single  case  before  curing  it. 

Such  are  some  of  the  minor  and  least  frequent  lesions  about  the  face 
and  mouth.  We  must  now  consider  a  lesion  commoner  and  far  more 
serious  than  harelip  or  cleft -palate  even. 

CANCER  OF  THE   LIP 

Epithelioma  of  the  lip  (squamous-celled  cancer)  is  the  most  common 
of  the  malignant  diseases  of  the  face,  and  makes  up  nearly  50  per  cent, 
of  all  cases  of  face  cancer.  It  is  an  interesting  fact  that  men,  almost  ex- 
clusively, are  the  victims  of  cancer  of  the  lip ;  we  see  it  so  rarely  in  women 


CANCKH    OF  THK    LIP  549 

that  in  them  it  is  regarded  as  a  curiosity.  Moreover,  the  predisposition 
to  cancer  of  the  Hp  increases  as  men  grow  older,  while  the  disease  is 
extremely  r:uc  in  person^  under  forty.  The  causation  of  lip  cancer  is 
manifold.  It  may  be  due  to  various  anomalies  of  the  skin,  which  are 
common  enough  about  the  lips,  such  as  warts,  pigmented  spots,  papil- 
lomata,  hypertrophies  of  glands  and  follicles,  and  chronic  inflammatory 
diseases,  but  it  is  a  curious  fact  that  such  common  lesions  rarely  lead  to 
cancer,  except  in  the  lower  lip.  Cancer  of  the  upper  lip  is  excessively 
uncommon.  One  cannot  avoid  the  conclusion,  moreover,  that  long- 
continued  chronic  irritation  of  the  lip,  as  from  an  old  scar,  and  especially 
from  pipe-smoking,  is  an  important  element  in  the  etiology  of  lip  cancer. 
The  disease  is  generally  situated  at  one  side,  rarely  in  the  middle  of  the 


^If  ' 

-'     '^ 

■ :/ 

y 

/-^.^.\ 

'i  " 

.  >^^^^ 

4 

I 

%> 

'y^ 

aHH^ 

Fig.  361. — Carcinoma  of  neck,  secondary  to  lip  cancer  (Massachusetts  Greneral  Hos- 
pital) . 

lip,  and  is  a  process  of  slow  progress.  For  this  reason,  as  with  other 
cancers  of  the  face,  and  because  these  lesions  are  on  the  surface  and 
quickly  detected,  it  seems  as  though  a  cure  of  the  growths  should  be 
common  and  easy.  Cancer  of  the  lip,  however,  differs  from  most  other 
facial  skin  cancers  in  this  respect,  that  it  involves  lymph-nodes  much 
more  early  than  do  they. 

Lip  cancer  appears  at  first  generally  as  a  scab  covering  a  small,  hard, 
granulating  tumor, — perhaps  a  perithelioma. — no  larger  often  than  half 
a  split  pea.  The  patient  picks  ofT  the  scab  or  it  falls  off,  and  then  gradu- 
all}'  it  forms  again.  This  stage  may  last  for  two  or  three  years,  but  even- 
tually the  growth  spreads  and  exfoliates.     When  once  started  in  this 


550 


THE  facf:  axd  neck 


way  it  may  increase  rapidl}',  and  within  a  few  months  the  whole  lower  lip 
is  a  mass  of  foul,  bleeding,  fungus  granulations,  with  an  extensive  in- 
durated base.  Although  this  state  of  progress  in  lip  cancer  should  never 
be  reached  in  any  civilized  conmumity,  the  condition  is  seen  not  uncom- 
monly. Perhaps  unfortunately,  the  patient  suffeis  little  discomfort  from 
lip  cancer  until  it  is  well  advanced,  and  he  may  carry  with  him  for  years 
a  threatening  nodule  without  being  especially  disturbed.  In  the  later 
stages  of  the  disease  great  distress  comes  on,  especially  pain,  debility, 
pain  in  the  jaw  from  involvement  of  the  bone,  and  pain  in  the  neck 
from  metastases.  If  the  disease  runs  an  uninteirupted  course,  the 
patient  dies  in  from  three  to  five  years,  with  great  swelling  of  the  neck, 
constant  pain,  perhaps  pressure  on  the  trachea,  and  obstruction  of  the 


Fig.  362. — Extensive  epithelioma  of  lip  (Massachusetts  General  Hospital). 

esophagus  even.  Distant  metastases  are  uncommon,  for  the  disease  is 
nearly  always  limited  by  the  collar  of  lymphatics  above  the  clavicle. 
One  should  observe,  moreover,  that  early  lymphatic  enlargements  are 
confined  to  a  few  nodes  in  the  submaxillary  and  submental  regions; 
lymphatic  swellings  lower  down  in  the  neck  along  the  edge  of  the  sterno- 
mastoid  appear  late,  and  in  this  respect  cancer  of  the  lip  differs  from 
cancer  of  the  tongue,  in  which  latter  disease  deep  lymphatic  involvement 
is  relatively  early. 

Probably  no  class  of  cancer  patients  have  fallen  victims  to  the 
malpractice  of  quacks  so  frequently  as  persons  suffering  from  cancer  of 
the  lip,  yet  it  should  be  obvious  to  every  qualified  physician  that  cancer 
of  the  lip  in  its  method  of  growth  is  analogous  to  cancer  of  the  breast, 


CANCER  OF  THE   LIP 


551 


and  demands  equally  thorough  and  far-reaching  cxtii'pation.  I  be- 
lieve that  a  mere  local  removal  of  young  lip  cancer  is  always  improper 
— as  improper  as  the  mere  local  removal  of  a  small  breast  cancer. 

The  treatment  of  lip  cancer  must  be  thorough  and  early  therefore, 
and  when  such  treatment  properly  is  followed,  the  surgeon  should  look 
for  a  large  percentage  of  permanent  cures.  For  some  years  I  have  fol- 
lowed the  technic  advocated  by  Crile."^  While  I  believe  firmly  in  ex- 
tensive dissection  of  the  neck  for  cancer  of  the  lip,  I  agree  with  Crile 
that  such  extensive  dissection  need  not  be  invariable.  In  operating  for 
early  cancer  it  is  enough  to  remove  thoroughly  the  growth  in  the  lip  and 
to  dissect  out  the  tissue — fat,  platysma,  vessels,  and  lymphatic  and  sali- 
vary glands  in  the  digastric  region,  corresponding  to  the  side  on  which 


Fk 


363. — Grant's  operation  for  cancer  of  lip — step  1. 


the  cancer  is  placed.  The  decision  regarding  more  extensive  operation 
sometimes  is  difficult.  A  good  general  rule  is  to  dissect  widely  the  neck 
only  in  case  one  finds  that  the  superficial  glands  are  involved. 

The  problem  of  the  operation  for  lip  cancer,  therefore,  divides  itself 
naturally  into  two  portions — the  operation  on  the  lip  and  the  operation 
on  the  neck.  The  operation  on  the  lip  should  be  done  more  thoroughly 
than  old  convention  enjoins.  The  common  method  has  been  to  remove 
the  growth  by  a  V-shaped  incision  and  to  sew  up  the  cleft.  This  is  poor 
surgery,  except  in  the  case  of  minute  growths,  for  when  a  large  growth  is 
removed  in  this  manner,  and  the  wide  gap  is  sewed  up,  there  results  an 
ugly,  disfigured  mouth — the  so-called  ''sucker  mouth."  The  best  incision 
for  removal  of  the  growth  itself  is  the  square  incision,  supplemented  by 

^  George  W.  Crile,  Jour.  Amer.  Med.  Assoc,  December  1,  1906,  p.  1780. 


552  THE   FACE   AND   NECK 

such  a  flap  operation  as  Grant's.'  By  this  operation  a  wide  clean  excision 
of  the  tumor  is  made.  From  the  inferior  angle  of  the  wound  cuts  are  then 
carried  down  obliquely  beneath  the  jaw;  the  submaxillary  region  is  ex- 
posed; the  suspicious  area  is  di.ssected,  and  the  resulting  extensive  wound 
is  closed  readily  by  a  flap-sliding  plastic.  A  fairly  shapely  mouth  re- 
sults from  the  most  extensive  dissection  even,  and,  if  necessary,  any 
lack  of  mucous  border  may  be  supplied  from  a  splitting  plastic  of  the 
upper  lip — Sandelin's  cheiloplasty. 

The  more  extensive  and  radical  dis.section  of  the  neck  (Crile)  is  an 
operation  of  the  first  magnitude,  and  in  undertaking  it  one  should  have 
regard  to  three  important  considerations— infection,  hemorrhage,  and 
shock,  as  well  as  the  primar}-  consideration  of  radical  cure.     A  suitable 


J0  .^  ^ 


L^ 


Fig.  3fi4. — Grant's  oporation  for  cancer  of  lip — step  2. 

method  of  approach  is  through  a  T-shaped  incision — the  horizontal 
running  beneath  the  jaw  from  the  symphysis  to  the  mastoid;  the  per- 
pendicular from  the  angle  of  the  jaw  to  the  niidtile  of  the  clavicle,  cross- 
ing obIir{uely  the  sternomastoid  muscle.  One  turns  back  freely  these 
flaps  and  proceeds,  as  in  the  removal  of  breast  cancer,  to  take  out  the 
whole  of  the  infected  area,  including  in  the  dissection  fascia,  fat,  sali- 
vary and  part  of  the  parotid  glands,  sternomastoid,  omohyoid,  and  part  of 
the  stylohyoid  muscles,  the  entire  venous  system,  and  all  the  lymphatic 
vessels  and  glands  in  this  region.  This  comprehensive  dissection  is  quite 
as  extensive  and  complete  as  the  thorough  dissection  for  breast  cancer. 
One  begins  the  deep  dissection  from  below,  cutting  away  the  sterno- 
mastoid close  to  the  clavicle,  reflecting  it  upward,  tying  the  deep  and  su- 

-  W.  W.  Grant,  Jour.  Amer.  Med.  Assoc,  September  30,  1905,  p.  962. 


CANCER    OF   THE    LIP 


553 


juM-ficial  ju.uulars,  and  conti-()lliii<;-  possible  hcniorrha^c  b}' the  temporary 
i-laiups  of  Crile  plucecl  u]Jon  the  common  carotid.     With  this  as  a  bciiin- 


Fig.  365. — Grant's  operation  for  cancer  of  lip — step  3. 


Fig.  366. — Grant's  operation  for  cancer  of  lip — step  4. 

ning,  all  the  parts  I  have  named  may  be  freely  and  rapidly  removed, 
peeling  from  below  upward,  avoiding  possible  infection  by  handling  the 
mass  as  little  as  possible,  minimizing  hemorrhage  by  controlling  quickly 


554 


THE    P'ACE    AND    NECK 


all  severed  vessels,  and  obviating  shock  b}-  the  application  of  the  pneu- 
matic suit.  As  1  have  insisted  previously  in  discussing  the  removal  of 
cancer,  we  must  not  be  goverend  by  considerations  of  anatomy.  The 
loss  of  the  sternomastoid  and  other  muscles  is  quickly  compensated ;  the 
loss  of  a  large  part  of  the  venous  system  is  of  no  moment  whatever,  for 
numerous  veins,  deep  and  superficial,  quickly  enlarge  to  supply  the  lack; 
control  of  the  carotid  is  temporary  only,  and  in  a  large  experience  1 
have  seen  no  damage  follow  the  use  of  Crile's  clamp  carefully  applied  to 
that  vessel  without  forcible  compression.  This  neck  dissection  is  a  some- 
what formidable  oi)eration,  and  may  result  disastrously  if  any  of  the 
suggested  precautions  arc  neglected.  Moreover,  one  should  take  e\-ery 
pains  to  avoid  damaging  the  pneumogastric  nerve  with  its  connections. 
On  completing  the  dissection  one  sees  a  broad,  clean,  deep  wound,  at 
the  bottom  of  which  lie  arteries  and  nerves  only  upon  the  deep  cervical 
muscles.  Sew  up  the  wound  carefully,  and  leave  a  cigaret  drain  at  its 
lowest  angle.  Rapid  healing  is  promoted  by  supporting  firmly  the  neck 
for  a  w^eek  in  a  Thomas  collar  or  some  similar  device. 

Let  me  say  to  the  practitioner  that  I  am  aware  some  surgeons  doubt 
the  wisdom  of  this  wide  operation,  but  abundant  experience  of  my 
own  and  the  still  wider  experience  of  Crile  and  others  have  convinced  me 
that  nothing  short  of  this  gives  reliable  promise  of  permanent  cure  in 
grave  cases  of  extensive  cancer  of  the  lip  and  neck.  It  seems  almost 
needless  to  say  that  involvement  of  both  sides  of  the  neck  with  massive 
tumors,  that  profound  cachexia,  and  the  suspicion  of  distant  metastases 
contraindicate  positively  any  operation  whatever. 

Another  form  of  cancer  of  the  face  is  that  curious  and  unique  process 
which  we  call  rodent  ulcer. 

RODENT  ULCER 

This  is  a  cancer  originating  in  the  sebaceous  glands.  The  disease 
may  arise  anywhere  on  the  face — especially  on  the  nose,  eyelids,  and 


Fio;.  .367. — Rodent  ulcer. 

cheeks.     Its  first  manifestation  is  a  little  knob  about  the  size  of  a  split 
pea,  harmless  and  little  noticed.     The  knob  may  remain  for  years,  when 


INJURIES    OF   THE    FACE  555 

suddenly,  without  obvious  reason,  it  begins  to  ulcerate  and  to  progress, 
destroying  all  the  superficial  parts  in  its  neighborhood — skin,  muscles, 
fat,  cartilage,  eyeball,  and  bone — producing  a  horrible  disfigurement. 
It  grows  unceasingly;  it  is  painless;  it  gives  rise  to  no  metastases;  it 
appears  as  a  raw,  sloughing,  indolent  ulcer.  Its  origin  is  in  the  sebaceous 
glands,  as  I  have  said,  and  the  little  original  nodule  is  seen  microscopically 
to  consist  of  gland-ducts  filled  with  epithelium. 

For  years  surgeons  treated  rodent  ulcer  by  the  cautery  and  by  ex- 
cision, followed  b}^  extensive  plastic  operations.  Of  late  we  have  come 
to  believe  that  when  exposed  to  radium,  the  disease  is  aborted  rapidly, 
and  the  ulcer  heals  without  leaving  a  scar} 

There  are  sundry  other  injuries  and  diseases  of  the  face,  at  a  few  of 
which  it  may  pay  us  to  glance. 

INJURIES  OF  THE  FACE 

Injuries  of  the  face,  when  promptly  treated,  heal  rapidly,  for  the 
tissues  of  the  face  are  remarkably  vascular  and  primary  union  there 
occurs  in  a  few  hours.  Infected  wounds  even  are  subdued  more  readily, 
as  a  iTile,  than  are  similar  wounds  elsewhere.  One  of  the  commonest 
types  of  infection  of  the  face  is — 

Facial  Erysipelas. — This  is  due  to  streptococci,  which  find  lodgment 
in  some  crack  or  trifling  abrasion.  It  is  a  surgical  affection.-  The  result- 
ing inflammation  spreads  rapidlj' — commonly  about  the  eyes  as  a  center. 
It  presents  the  appearance  of  a  uniform  scarlet  blush  or  injection  of  the 
skin,  with  a  sharply  marked  outline.  Generally,  the  disease  runs  a  short 
course,  and  in  a  few  days  disappears  spontaneously;  but  if  unchecked, 
it  may  progress  indefinitely  over  the  body;  the  infection  may  burrow, 
and  there  may  result  extreme  deep  inflammations  with  pus — a  condition 
known  in  former  times  as  "  phlegmonous  erysipelas." 

An  excellent  treatryient  in  the  "early  stages  of  the  infection  consists  in 
the  frequent  application  of  a  lotion  composed  of  alcohol  and  carbolic 
acid.^  In  spite  of  the  feebleness  of  this  antiseptic  it  generally  succeeds 
in  quelling  the  disturbance  in  a  few  hours  or  days.  Another  popular 
treatment  consists  in  painting  the  edges  of  the  advancing  inflammation 
with  ichthyol.  When  the  infection  has  progressed  far  and  has  involved 
deeper  structures,  it  must  be  treated  vigorously  by  incisions  and  anti- 
septic dressings.  I  am  coming  to  believe  that  opsonic  vaccines  will 
mitigate  or  abort  this  infection,  but  at  present  the  evidence  is  not  con- 
clusive. 

Carbuncle  of  the  upper  lip  deserves  a  word  of  mention  here,  in 
addition  to  the  consideration  of  carbuncle  in  general,  which  the  reader 
will  find  in  Chapter  XXVI.  Carbuncle  of  the  upper  hp  is  peculiarly 
serious.  It  is  situated  in  an  extremely  vascular  region,  and  often  goes 
unrecognized  for  many  days — especially  in  the  case  of  a  bearded  lip; 

1  Tumors,  Innocent  and  Malignant,  J.  Bland-Sutton,  1907,  fourth  ed.,  p.  325. 

2  A  rather  convenient  cant  term,  which  implies  that  the  treatment  of  the  case 
should  be  in  the  hands  of  a  surgeon,  as  an  operation  may  prove  necessary. 

3  I^.  Acid,  carbolic,  4.00;  spirit,  vini  recti.,  30.00;  aquae,  ad  200.00. 


556 


THE    FACE    AND    NECK 


often  it  is  progressive  and  fatal  even,  involving  eventually  deep  stnic- 
tures  of  the  face  and  neck  and  spreading  perhaps  to  the  meninges.  The 
surgeon  should  treat  it  vigorously  at  the  outset,  by  excising  the  nidus  of 
infection,  if  such  excision  does  not  mean  extensive  crippling  of  the  face, 
or  by  deep  crucial  incisions  and  cureting.  At  the  same  time  he  should 
employ  opsonic  vaccines.  If  the  inflannnation  has  extended  far,  the. 
siu'geon  must  meet  the  indications  by  appropriate  far-reaching  incisions 
for  drainage. 

TUMORS  OF  THE  FACE 

Angioma,  a  tumor  composed  of  an  abnormal  formation  of  blood- 
vessels, is  common  on  the  face,  and  is  seen  in  three  forms:  (1)  Simple 
nevus;  (2)  cavernous  nevus;  (3)  cirsoid  aneurysm.  The  simple  nevus  is 
far  the  most  common,  and  is  ordinarily  designated  "  birth-mark."  It 
may  be  small  and  superficial  or  it  may  be  so  extensive  as  to  cover  the 
side  of  the  face — the  so-called  ''  port-wine  stain."  Nevi  are  composed 
of  minute  blood-vessels  embedded  in  fat  and  communicating  with  an 


Fig.  368. — Nevus  (Massachusetts  General  Hospital). 

adjacent  artery  or  vein.  Cavernous  nevi,  sometimes  called  erectile 
tumors,  are  made  up  of  spaces  and  sinuses,  the  walls  of  which  are  merely 
fibrous  septa  lined  with  epithelium.  Sometimes  the  cavernous  nevi 
consist  in  part  of  vessels  and  in  part  of  cavernous  spaces.  Like  simple 
nevi,  they  are  general!}^  congenital,  but,  unlike  simple  nevi,  they  grow. 
They  may  burst  and  bleed;  they  may  press  upon  such  organs  as  the 
tongue  and  nares,  and  then  rupture,  endangering  life  even. 

These  two  forms  of  nevus  may  be  treated  by  excision  if  they  be  not  too 


TUMORS    OF   THE    FACE 


557 


extensive,  or,  in  the  case  of  caveinous  nevi,  by  the  injection  of  boiUng 
water  into  the  mass.  The  latter  method  is  simple.  Boiling  water  is 
forced  through  a  common  hypodermic  needle,  inserted  in  several  places 
into  and  beneath  the  nevus,  until  all  parts  of  the  tumor  have  been 
reached.  There  results  coagulation  and  necrosis,  with  subsequent 
absor])tion  and  more  or  less  fibrous  tissue  formation,  but  ultimately 
with  pleasing  cosmetic  results.  More  than  one  sitting  may  be  required, 
and  many  months  may  pass  before  the  swelling  disappears  entirely.' 

Cirsoid  aneurysm  consists  of  numerous  arteries  arranged  in  a  tor- 
tuous fashion.     These  angiomata  are  rare,  disfiguring,  troublesome,  or 


Fig.  369.- — Treatment  of  nevus  by  boiling  water. 

in  the  end  dangerous,  and  can  be  treated  by  careful  excision  only. 
When  the  whole  mass  becomes  so  extensive  as  to  involve  half  the 
forehead  or  more  even,  its  cure  is  extremely  diflficult,  and  requires 
numerous  successive  operations,  with  careful  painstaking  dissection. 

So  much  for  the  lesions  of  the  face  which  concern  the  surgeon  especi- 
ally. There  are  in  this  region  numerous  other  disorders  involving  the 
skin  and  special  organs,  but  for  the  study  and  treatment  of  these  dis- 
orders I  must  refer  the  reader  to  appropriate  special  treatises. 

^  Recently  surgeons  have  successfully  removed  nevi  by  applications  of  liquid  air 
or  carbon-dioxid  snow. 


CHAPTER  XXI 

JAWS,  TONGUE,  LARYNX,  AND  PHARYNX 

The  Jaws 

The  surgery  of  the  tongue  and  jaws  is  associated  closely  with  the 
surgery  of  the  face, — the  subject  of  the  preceding  chapter, — as  well  as 
with  the  surgery  of  the  neck.  The  lesions  of  these  parts  are  of  supreme 
importance  not  only  to  life  and  health,  but  to  comeliness  and  beauty, 
so  that,  in  a  large  sense,  they  should  fall  to  specialists.  Indeed,  certain 
portions  of  the  problem  have  been  divided  among  certain  specialists — 
laryngologists  and  dentists — upon  whose  field  I  intend  to  trespass  but 
little.  There  are,  however,  many  associated  lesions  which  fall  as  yet 
to  general  surgeons.  There  are  fractures,  deformities,  malignant  tumors, 
and  infections  in  great  variety,  at  most  of  which  we  must  glance.  A 
special  study  of  all  these  lesions  is  impossible  in  our  limited  pages,  but 
I  shall  take  occasion  to  refer  the  reader  to  sundry  important  essays  and 
monographs.  Fractures  and  dislocations  of  the  jaws  will  be  considered 
under  a  special  chapter  of  this  book,  on  the  general  subject  of  fractures 
(Chapter  XXIX). 

The  buccal  cavity  is  peculiarly  liable  to  infections,  because  the 
mouth  is  a  swarming  breeding-place  of  micro-organisms,  which  may 
find  ready  lodgment  about  the  teeth  and  gums  or  in  cracks  of  the  tongue 
and  lips,  and  so  produce  infections.  Moreover,  the  mouth  is  a  cloaca 
concerned  with  both  the  respiratory  and  the  digestive  tracts,  so  that 
infections  and  lesions  of  the  mouth,  fauces,  stomach,  and  air-passages 
may  be  related  and  interdependent.  The  mouth,  jaws,  and  tong-ue 
are  peculiarly  liable  to  injuries  and  irritations;  the  head  and  face  are 
at  all  times  exposed  to  the  weather  and  to  violence,  while  the  tongue 
and  cheeks,  lying  in  contact  with  the  teeth,  may  suffer  from  such 
contact,  especially  if  the  teeth  be  broken,  jagged,  and  decaj'ed.  The 
development  of  the  teeth  themselves,  their  relation  to  health,  to  their 
own  function  in  digestion,  and  to  anatomic  obstructions  by  tumors 
and  deformities  in  the  mouth,  fauces,  and  nasal  passages,  all  go  to  make 
up  an  independent  and  important  chapter  in  surgery.  As  I  said  in 
speaking  of  face  lesions,  the  surgery  of  all  these  parts  differs  from  most 
other  surgery  in  that  it  has  in  it  a  peculiar  factor — the  factor  of  possible 
cosmetic  deformity.  Aside  from  this  factor,  which  one  must  constantly 
be  considering,  one  must  regard  possible  involvements  of  the  special 
senses.  There  are,  however,  three  main  types  of  lesions  which  we  must 
study  in  this  chapter — infections,  injuries  (and  their  results),  and 
tumors. 

558 


INFECTIONS  559 


INFECTIONS 


Alveolar  abscess  ("  gum-boil")  is  a  common  and  distressing  affec- 
tion. It  appears  as  a  painful,  throbbing  swelling  of  the  gum,  quickly 
followed  by  an  associated  swelling  of  the  cheek,  which  assumes  an  ap- 
pearance of  ludicrous  deformity  within  a  few  hours.  The  infection 
starts  in  or  about  the  root  of  a  tooth,  quickly  involves  the  periosteum, 
and  spreads  to  the  mucosa.  If  you  examine  it  with  your  finger,  you 
find  a  sensitive  area  on  the  gum  over  the  affected  tooth,  with  swelling 
of  the  gum  extending  to  the  cheek.  Within  a  day  or  two  you  find  the 
swelling  to  be  fluctuant.  If  left  untreated,  this  little  abscess  will  open 
and  discharge,  but  after  a  number  of  days  only.  In  its  early  hours  the 
inflammation  may  sometimes  be  aborted  by  the  frequent  use  of  hot 
myrrh  mouth-washes  and  small  internal  poultices,  worn  within  the 
mouth.  Large  external  poultices  are  comforting,  but  one  should  not 
depend  upon  them  too  long,  as  they  may  encourage  the  burrowing  of  pus 
and  its  opening  through  the  cheek,  especially  when  the  abscess  springs 
from  the  lower  jaw.  In  all  cases,  however,  the  surgeon  should  cocainize 
and  open  the  g-um-boil  as  soon  as  it  shows  signs  of  fluctuation.  The 
relief  is  instantaneous  and  the  cure  prompt.  Later,  the  patient  should 
consult  his  dentist  for  repair  of _  the  tooth  which  has  set  up  the  trouble. 
Sometimes  these  infections  progress  deeply  and  result  in  osteomyelitis 
of  the  jaw"  bones. 

Osteomyelitis  may  be  due  to  other  causes — to  some  general  systemic 
infection,  to  some  localized  infection  of  the  mouth,  or  to  phosphorus- 
poisoning.  The  progress  of  such  bone  infections  is  rapid  and  extremely 
painful.  Their  seat  commonly  is  in  the  lower  jaw,  because  the  mandible 
only  has  a  medullary  cavity.  Destruction  of  considerable  areas  of  bone 
or  of  the  whole  jaM'  even  may  result,  wdth  extensive  suppuration,  se- 
questrum formation,  and  dropping  out  of  the  teeth.  Active  surgical 
treatment  is  imperative — early  free  incision,  opening  of  the  medullary 
cavity,  and  competent  drainage.  If  such  prompt  treatment  has  been 
neglected,  the  surgeon  finds  himself  consulted  by  the  patient  in  an  ad- 
vanced stage  of  chronic  bone  disease,  with  burrowing  sinuses,  at  the 
bottom  of  which  lie  bare  bone  and  necrotic  sequestra.  Such  a  condition 
necessitates  a  tedious  form  of  treatment — laying  open  the  sinuses,  ex- 
posing the  bone,  removing  the  sequestra,  and  looking  for  a  slow  repair, 
should  a  proper  amount  of  periosteum  and  endosteum  be  left  for  repair. 
A  cure  in  such  fashion  cannot  always  be  expected,  however,  and  exten- 
sive destruction  of  the  jaw^,  wdth  serious  crippling  and  deformity,  may 
result.  This  unfortunate  condition  will  tax  to  the  utmost  the  resources 
of  the  surgeon,  and  will  lead  him  to  attempt  some  form  of  plastic  re- 
construction.^ 

There  are  other  and  more  insidious  forms  of  infections  of  the  jaw 
bones.  The  so-called  necrotic  caries  is  a  familiar  example  of  chronic 
disease  of  the  jaws — a  disease  which  attacks  by  preference  the  superior 

^  Carl  Beck,  Plastic  Reconstruction  of  the  Lower  Jaw,  Jour.  Amer.  Med.  Assoc, 
April  21,  1906. 


5(30  THE    FACE    AND    NECK 

maxillary  bone  at  the  infia-oibital  rid^e  and  the  malar  bone.  It  is 
usually  of  tuberculous  origin,  and  must  be  treated  by  vigorous  cureting, 
the  removal  of  all  obviously  necrotic  tissue,  and  the  enjoining  of  an  out- 
of-doors  life.  There  results,  after  the  healing,  an  ugly  facial  scar,  often 
causing  ectropion  of  the  lid,  which  must  be  corrected  by  a  subsequent 
operation. 

One  of  the  commonest  and  most  obstinate  infections  of  tlie  upper 
jaw  is  that  which  involves  the  antrum  of  Highmore  and  leads  to  em- 
l)3'ema  of  the  antrum.  This  infection  ma}-  originate  either  in  the  teeth 
or  in  the  nasal  bones.  It  belongs  properly  to  the  throat  specialist,  and 
I  refer  the  reader  to  special  monographs  and  larger  works  on  this 
subject. 

Besides  these  immediate  and  active  results  of  acute  infections  of  the 
jaws  the  surgeon  must  deal  with  their  after-results,  most  conspicuous 
among  which  is  lock-jaw.  Mechanical  lock-jaw  originating  in  tlisease 
of  the  mandible  is  rare,  but  lock-jaw  resulting  from  disease  of  the  soft 
parts  of  the  mouth  and  face,  which  cause  contractions,  is  much  more 
common.  The  latter  form  of  lock-jaw  is  that  which  we  see  frequentl}'' 
in  out-patient  clinics,  and  its  treatment  taxes  severely  the  surgeon's 
patience  and  ingenuity.^  The  contractures  are  due  directly  to  solid, 
cord-like  bands  of  tissue,  following  destructive  ulcerative  changes  (noma) 
which  have  their  origin,  as  a  rule,  in  the  buccal  mucosa.  The  rare 
arthritic  bony  fusion  must  be  treated  by  partial  excision  of  the  joint, 
but  the  treatment  of  the  cicatricial  contractures  is  another  matter. 
These  contractures,  which  occur  most  often  in  young  children,  ai'c  a  grave 
menace  to  health;  the  jaw  becomes  set;  mastication  is  impossible; 
the  patient  must  live  on  liquid  nourishment ;  the  teeth  become  dwarfed, 
deformed,  and  diseased;  the  mandible  itself  fails  of  development,  so 
that  the  facial  expression  and  outline  become  distorted,  and  the  patient 
suffers  grievously  in  both  mind  and  body.  If  these  contractures  be  seen 
early  and  are  unilateral,  vigorous  mechanical  treatment  may  suffice  for 
a  cure.  Implements  are  used  for  the  purpose  of  forcing  apart  the 
jaws  and  enabling  the  patient  to  pursue  a  course  of  ruminant  gymnastics. 
A  great  variety  of  apparatus  has  been  divised  for  this  purpose — wooden 
thumb-screws  and  wedges  are  the  most  familiar,  but  their  use  involves 
the  serious  disadvantage  that  they  may  break  or  otherwise  damage  the 
teeth.  ]\Ioreover,  their  employment  is  extremely  painful.  Curtis  ^ 
has  employed  a  double  screw-plate  which  is  serviceable.  By  such 
means  it  frequently  happens  that  a  satisfactory  jaw  is  secured.  On 
the  other  hand,  old  neglected  cases  cannot  be  so  treated.  These  are  the 
cases  in  which  the  lesions  are  cicatricial  and  bilateral,  and  have  persisted 
so  long  and  are  so  deeply  placed  that  degenerative  and  developmental 
changes  in  the  mandible  and  its  condyle  have  taken  place.  Sometimes 
one  may  gain  a  certain  amount  of  motion  by  dividing  the  cicatricial 
bands  and  employing  mechanical  massage,  but  for  the  more  serious  cases 

^  Rudolph  Matas,  Operative  Treatment  of  Bilateral  Cicatricial  Ankylosis  of  the 
Jaws,  Jour.  Amer.  Med.  Assoc,  November  28,  1903. 

-  G.  Lenox  Curtis,  Ankylosis  of  the  Jaws,  ibid.,  July  2,  1904. 


TU.MOR.S   OF   THE    JAWS 


)61 


some  form  of  extensive  plastic  operation  is  required — splitting  the 
cheek  and  turning  into  the  buccal  cavity  skin-flaps  from  the  face  or  neck. 
A  number  of  ingenious  procedures  of  this  kind  have  been  devised,  for  a 
stud}-  of  which  1  refer  the  reader  to  flatus's  valuable  paper. ^ 

TUMORS   OF   THE   JAWS 

Tumors  of  the  jaws  are  common  also,  especially  benign  tumors, 
because  the  maxillary  bones,  on  account  of  their  peculiar  formation, 
the  fact  of  dentition,  the  presence  of  the  antmm,  and  irritations 
arising  in  the  buccal  cavity  arc  especially  disposed  to  tumor  formations. 
There  is  the  subperiosteal  cyst  of  the  alveolar  process,  which  orig- 
inates in  a  subperiosteal  abscess,  with  the  separation  of  the  periosteum 
and  the  subsequent  formation  of  a  new  bony  laj-er  which  ma}'  cause  the 
formation  of  a  considerable  swelling,  either  crepitant  or  solid  to  the  touch. 
Such  a  cyst  sometimes  is  cured  by  drainage  through  the  extraction  of 
carious  teeth;  sometimes  it  is  necessary  to  incise  and  curet  the  cvst. 


Fig.  370. — The  second  right  mandibular  molar  of  a  Chinaman,  aged  nineteen 
years,  with  a  swelling  possessing  the  characters  of  a  composite  odontoma:  A  and  B, 
Tooth,  natural  size;  C,  enlarged  and  in  section  (Keen's  Surgeiy). 

Fibromata  of  the  jaws  are  not  very  common,  but  one  finds  them 
occasionally  on  the  alveolar  process  about  the  canine  teeth.  Carefid  re- 
section of  the  alveolar  process  is  necessary  for  their  cure. 

Odontomata  and  dental  cysts  are  the  most  troublesome  and  fre- 
quent tumors  of  the  jaw.  They  spring  from  dental  tissue  at  different 
stages  of  its  development,  from  teeth  germs  or  teeth  still  in  the  process 
of  growth.  Bland-Sutton  ^  has  given  us  an  extremely  interesting  chapter 
on  this  subject  in  the  last  edition  of  his  valuable  book. 

It  is  needless  to  discuss  the  seven  varieties  of  odontomata.  Suffice 
it  to  say  that  these  peculiar  growths  consist  of  structures  of  varying 
histologic  type  and  arrangement,  and  that  they  produce  bone-like  swell- 
ings of  considerable  size,  which  contain  spaces  in  which  are  found  frag- 
ments of  teeth  or  whole  teeth  unerupted  and  embedded.  Odontomata 
may  occur  in  either  the  upper  or  the  lower  jaM-,  and  the  follicular  species 

1  Rudolph  Matas,  ibid.  , 

2  J.  Bland-Sutton,  Tumors,  Innocent  and  Malignant,  fourth  ed.,  1907,  p.  227. 

36 


562 


THE    FACE    AND    NECK 


is  often  multiple.  That  form  known  as  the  composite  species  may  in- 
vade the  antrum  and  attain  the  size  of  an  infant's  fist.  An  important 
point  in  their  clinical  history  is  that  in  nearly  all  these  cases  the  tumor 
remains  quiescent  for  a  period,  and  that  then  there  comes  a  time  in 
which,  like  the  teeth,  it  seems  to  erupt,  making  its  way  above  the  gum, 
and  causing  often  profound  constitutional  disturbances  of  a  septic 
character.  This  phenomenon  of  eruption  occurs  usually  between  the 
twentieth  and  twenty-fifth  years.  The  diagnosis  of  these  tumors  has 
been  a  matter  of  great  difficulty  in  the  past,  and  the  growths  have  been 
regarded  often  as  malignant  neoplasms.    Fortunately,  to-day  the  x-rays 

serve  to  clear  up    obscure   diagnoses  by 
showing  cysts  and  unempted  teeth. 

Odontomata  have  been  objects  of  a 
deal  of  bad  surgery  in  the  past,  and  com- 
petent operators,  influenced  by  mistakes 
in  diagnosis,  have  removed  large  jjor- 
tions  of  the  jaw.  No  such  disabling 
operations  are  necessary.  In  the  case 
of  a  questionable  tumor  of  the  jaw,  es- 
pecially in  a  young  person,  the  surgeon 
should  ascertain  its  peculiar  character  by 
the  a:-rays  or  by  microscopic  study,  if 
necessary.  An  odontoma  requires  merely 
enucleation  of  the  growth,  while  one 
peculiar  form  onh",  the  follicular  odon- 
toma, demands  complete  removal  of  the 
sac. 
Dental  cysts  are  growths  connected  with  the  roots  of  teeth,  from 
which  they  hang  ofl"  as  a  cherry  hangs  from  its  stem.  These  cysts  are 
fibrous  bags  filled  with  a  mucoid  fluid.  They  vary  from  the  size  of  an 
apple  seed  to  that  of  an  English  walnut,  and  frequently  are  connected 
with  the  dead  roots  of  molars  in  either  the  upper  or  lower  jaw.  These 
cysts  do  not  contain  teeth,  as  do  the  tme  odontomata.  with  which  one 
should  not  confound  them.  The  c}'st  must  be  attacked  by  drawing  the 
teeth  involved,  enucleating  thoroughly  the  sac,  and  packing  the  cavity 
with  sterilized  gauze. 

While  the  odontomata  are  the  most  interesting  of  benign  tumors  of 
the  jaws,  there  are  sundry  other  tumors  which  are  more  YHYQ—osteomata, 
bony  outgrowths  which  offend  merely  by  their  size  and  pressure  upon 
special  structures— nerves,  the  eye,  the  nasal  cavities,  and  the  mouth: 
adenomata  and  chondromata  also;  but  they  are  quite  uncommon  as  com- 
pared with  malignant  tumors. 

Malignant  Tumors. — Of  these,  sarcoma  is  somewhat  more  com- 
mon than  cancer,  and  the  commonest  form  of  sarcoma  of  the  jaws  is 
of  that  giant-cell  type  known  to  surgeons  as  epulis. 

Epulis  is  one  of  the  least  malignant  forms  of  sarcoma.  It  arises 
from  the  periosteum  of  the  alveolar  process,  grows  slowly,  and  tends 
to  envelop  the  bone.    It  appears  at  the  edge  of  the  teeth  as  a  curious  pig- 


Fig.  371. — A  follicular  odon- 
toma from  the  right  half  of  the 
mandible  of  a  boy  aged  fourteen 
years  (Bland-Sutton  in  Keen's 
Surgery). 


TUMORS   OF   THE   JAWS 


563 


merited  excrescence,  and  is  the  only  form  of  pigmented  sarcoma  that 
is  not  exceedingly  malignant.  If  untreated,  it  spreads  gradually  so  as 
to  involve  largo  portions  of  the  jaw,  and  causes  falling  of  the  teeth  until 
eventually,  and  after  many  years,  it  kills  the  patient  through  encroach- 
ment upon,  and  destruction  of,  important  organs.  It  is  not  difficult  to 
.eradicate  epulis  early,  but  half-measures  do  not  avail.  The  surgeon 
must  draw  the  teeth  in  the  neighborhood  of  the  growth  and  excise 
thoroughly  the  tumor  with  the  adjacent  gum  and  a  portion  of  the  jaw, 
cutting  freely  about  the  disease  by  a  margin  of  one-half  inch  at  least. 
This  operation,  though  strictly  local  and  not  especially  deforming, 
cures  the  patient  permanently  in  most  cases.     If  the  growth  recurs,  it 


Fig.  372.— Epulis. 

recurs  locally  and  can  be  removed  surely  by  the  merest  local  treatment 
— by  excision,  the  cautery,  or  the  curet  even. 

Sarcoma  of  the  body  of  the  jaw  is  a  far  more  serious  matter  than 
epulis.  Epulis  is  a  disease  of  young  adult  life,  sarcoma  of  the  body  of 
the  jaw  is  a  disease  of  middle  age.  This  latter  form  of  tumor  is  a  round- 
cell  sarcoma  with  a  scanty  stroma.  It  appears  in  both  the  upper  and 
the  lower  jaws  and  extends  rapidly  until  it  involves  all  the  bones  of  the 
face,  as  well  as  the  neighboring  soft  parts.  It  recurs  commonly  after 
being  removed,  and  the  only  treatment  which  holds  out  any  promise 
of  cure  is  extensive  and  deforming  resection  of  all  the  parts  involved. 
The  upper  jaw  sometimes  is  the  seat  of  a  periosteal  sarcoma  arising 


564  THE    FACE    AXD    NEf'K 

from  the  gums,  though  the  conmion  situation  of  periosteal  sarcoma  is 
in  the  antrum,  where  it  causes  great  enlargement  of  the  bone  and  en- 
croaches ui>on  the  nasal  passages,  the  orbit,  and  the  sphenomaxillary, 
zygomatic,  and  temporal  fossa*.  This  is  a  tumor  of  rapid  growth.  It 
occurs  commonly  in  young  adults,  and  nuiy  kill  the  victim  within  a  year. 
Lymphatic  involvements  and  distant  metastases  rai'ely  are  associated 
with  these  sarcomata  of  the  jaws. 

Cancer  involves  the  jaws  but  secondarih-,  wheieas  sarcoma  there 
is  primary.  Cancer  spreads  from  the  soft  parts  to  the  neighboring  bones 
of  the  jaw.  Seldom  does  it  appear  before  middle  life.  Since  cancer 
attacks  the  bones  from  without  and  through  the  mouth,  it  is  almost 
ahvays  associated  with  infections  and  foul  ulceration.  The  victim  of 
cancer  about  the  jaws  is  an  object  loathsome  to  himself  and  to  those 
about  him.  Young  cancer  of  the  jaw  ma}'  simulate  epulis,  and  for  this 
reason  a  carefid  microscopic  study  invariably  should  be  made  of  growths 
about  the  base  of  the  teeth.  In  distinguishing  clinically  between  epulis 
and  cancer,  observe  that  cancer  ulcerates,  while  epulis  rareh'  does  so; 
and  that  cancer  produces  enlargement  of  the  lymph-nodes,  which  is  not 
true  of  epulis.  Extensive  cancer  may  involve  the  bony  fossa^  within 
and  behind  the  upper  jaw,  but  such  cancer  rarel}'  is  primary  there. 
Whether  primary  or  not,  the  surgeon  must  distinguish  it  from  the  rountl- 
cell  sarcomata  which  are  the  common  growths  of  that  region. 

Cancer  of  the  jaws  progresses  rapidl}'  when  once  it  has  become 
established,  and  may  destroy  the  patient  within  a  year.  It  invades  the 
orbit,  the  nasojoharynx,  the  submaxillary  region,  and  involves  exten- 
sively the  lymph-nodes  of  the  neck,  often  attacking  the  skin,  and 
appearing  externally  as  an  ulcerated,  sloughing  mass.  One  sees,  there- 
fore, that  cancer  in  the  deep  parts  of  the  face  calls  for  early  and 
thorough  treatment. 

Treatment  must  be  by  the  most  radical  excision  if  it  shall  avail. 
Various  forms  of  treatment  other  than  excision  have  been  advocated 
from  time  to  time;  but  although  the  x-rays  and  radium  have  seemed 
to  promise  something,  we  cannot  yet  avoid  the  conviction  that 
our  only,  though  feeble,  hope  of  cure  rests  in  the  knife.  It  is  a  disap- 
pointing fact  that  operations  for  cancer  within  and  about  the  mouth  and 
jaw's  seldom  cure.  So  true  is  this  that  surgeons  look  upon  a  patient  who 
is  well  three  years  or  more  after  a  radical  excision  of  cancer  about  the 
mouth  (except  cancer  of  the  lip)  as  a  curiosity.  Let  us  consider  briefly 
the  operations  of — 

Resections  of  the  Upper  and  Lower  Jaws. — These  operations,  with 
their  various  modifications  and  extensions,  form  the  feeble  staff  on  which 
we  must  lean  when  dealing  with  malignant  disease  of  this  region. 

The  upper  jnir  may  be  removed  with  a  resulting  deformity  sur- 
prisingly slight  when  one  considers  the  extent  and  severity  of  the  opera- 
tion. I  apply  a  clamp  to  the  carotid  as  a  preliminary  step.  Then, 
following  the  method  of  Ferguson,  one  turns  back  a  skin-flap  through  an 
M-shaped  incision  traced  along  the  inferior  rim  of  the  orbit,  the  base  of 
the  nose,  about  the  ala,  and  down  through  the  upper  lip.     I  prefer  to 


TUMORS  OF  THE    JAWS 


565 


operate  with  the  patient  in  the  upright  position,  as  he  can  thus  be  tipped 
forward  readily  for  the  expulsion  and  clearing  out  of  blood  and  mucus 
from  the  mouth.  However,  there  should  be  no  considerable  hemorrhage. 
Ether  anesthesia  with  the  ordinary  cone  is  satisfactory.  The  surgeon 
enters  the  knife  at  the  base  of  the  zygoma,  carries  it  at  once  down  to  the 
bone  and  completes  the  deep  incision  with  a  series  of  firm  sweeps. 
Then  he  turns  back  quickly  the  soft  parts  of  the  cheek  from  the  upper 
jaw,  exposing  completely,  thoroughly,  and  easily  all  those  bony  sti-uc- 
tures  which  are  to  be  removed.  He  then  controls  the  hemorrhage  in 
the  flap  and  proceeds  to  the  excision  of  the  maxilla  itself — an  under- 
taking less  difficult  than  would  appear  at  first  sight.  A  short,  powerful 
saw.  a  stout  knife,  and  a  pair  of  heavy  grasping  bone-forceps  are  the  im- 


Fig.  373. — Lines  of  incision  for  resection  of  the  upper  jaw  (Fowler). 

portant  instruments  required.  Detach  from  the  bone  the  nasal  cartil- 
ages at  the  edge  of  the  incision.  Divide  then  with  the  saw  the  nasal 
process  of  the  superior  maxilla,  from  the  junction  of  the  nasal  process 
with  the  lower  border  of  the  nasal  bone,  and  carry  the  cut  to  the  margin 
of  the  orbit  just  below  the  canal  of  the  nasal  duct.  Then  follows  the 
important  step  of  preserving  the  eye;  to  this  end  raise  the  periosteum 
from  the  floor  of  the  orbit  (together  with  the  origin  of  the  internal  ob- 
lique muscle)  and  retract  upward  these  soft  parts.  Chisel  obliquely 
across  the  orbital  plate  from  the  end  of  the  saw-cut  to  the  anterior  end 
of  the  sphenomaxillary  fissure.  This  clears  the  orbital  and  external 
surfaces  of  the  malar  bone.  Complete  the  division  of  the  malar  bone, 
using  the  straight  short  saw  or  the  Gigli  passed  through  the  spheno- 


566  THE    FACE   AND    NECK 

maxillary  fissure  and  zygomatic  fossa.  It  remains  to  extract  the  now 
loosened  maxilla.  To  effect  this,  divide  the  mucoperiosteal  covering 
of  the  hard  palate  in  the  median  line,  as  well  as  the  mucoperiosteal 
covering  of  the  floor  of  the  nose,  cutting  as  near  the  septum  as  possible. 
Then  make  a  transverse  cut  across  the  roof  of  the  mouth  at  the  junction 
of  the  hard  and  soft  palates,  and  with  a  saw  divide  the  horizontal  plate 
and  the  palatal  and  alveolar  portions  of  the  upper  jaw.  Now  grasp 
with  a  large  bone  forceps  the  seijarated  jaw  bone  and  break  it  away  from 
its  few  remaining  attachments.  It  separates  easily,  and  one  may  catch 
with  forceps  successively  the  bleeding  points  which  are  thus  brought 
into  view.     The  upper  jaw  being  removed,  a  vast  gajnng  cloaca  is  re- 


Fig.  374. — Resection  of  half  of  the  upper  jaw.     Dissection  of  the  flaj)  from  the  bone 

(Fowler). 

vealed,  which  I,  as  a  young  medical  student,  remember  gazing  upon  with 
fascinated  horror. 

The  healing  of  these  extensive  wounds  generally  is  prom])t  and  un- 
complicated. The  patient  suffers  surprisingly  little  discomfort,  except 
from  the  sense  of  loss  of  substance.  At  the  primary  dressing  of  the 
wound  there  is  need  for  considerable  packing  of  the  raw  cavity,  but 
granulations  quickly  spring  up,  and  the  packing  must  be  removed  and 
renewed  almost  daily  after  the  third  day.  By  the  end  of  two  weeks  a 
fair  degree  of  healing  is  established,  so  that  no  further  dressings  are 
necessary  beyond  the  frequent  irrigation  of  the  mouth  and  pharynx, 
which  must  be  continued  so  long  as  discharges  persist.  It  is  not  dif- 
ficult to  feed  these  patients.     They  may  be  nourished  through  a  nasal 


TUMORS   OF   THP]   JAWS 


567 


Fig.  375.- — Lion-jaw  forceps  grasping  the  resected  portion  of  the  upper  jaw  (Fowler) 


Fig.  376. — External  Incision  for  resection  of  half  of  lower  jaw  (Fowler), 


feeding-tube  for  a  few  days,  but  they  learn  to  swallow  naturally  in  a 
short  time. 


568 


THE    FACE    AND    NECK 


I  have  said  that  the  outlook  in  these  cases  is  not  encouraging. 
Occasionally  sarcomata  when  removed  do  not  return,  but  when  the 
operation  is  done  for  cancel-,  that  treatment  must  always  be  regarded  as 
a  palliation. 

Excision  of  the  lower  jaw  usually  means  excision  of  half  of  that  bone. 
Removal  of  the  whole  bone  is  done  rarely.  The  technic  of  removal  of 
half  of  the  lower  jaw  is  as  follows:  Control  hemorrhage  by  a  temporary 
clamp  on  the  carotid;  beginning  at  the  chin  make  a  vertical  cut  from 
just  below  the  border  of  the  lip  down  to  the  jaw  bone,  and  carry  the 
cut  around  the  angle  of  the  chin;  from  this  point,  with  the  knife  close  to 
the  bone,  carry  the  incision  along  the  mandible  up  to  and  beyond  its 
angle  nearly  to  the  ear,  stopping  short  of  the  facial  nerve;  take  up  the 


''^. 

'•n^ 


Fig.  .377. — Temporary  clamp  (Crile's)  on  carotid. 


facial  artery  as  the  knife  passes  it;  then  lift  the  periosteum  from  the  ex- 
ternal surface  of  the  bone,  from  the  symphysis  outward;  control  hemor- 
rhage; cut  away  the  buccal  mucosa  from  the  line  of  the  teeth;  extract 
one  of  the  incisor  teeth,  and  saw  through  the  symphysis ;  seize  the  loos- 
ened bone  with  heavy  forceps,  draw  it  outward  and  divide  the  various 
muscular  attachments — the  mylohyoid  muscle,  the  internal  pterygoid; 
the  temporal  and  the  external  pterygoid;  open  the  capsule  of  the  joint; 
cut  away  the  ligaments  and  remove  the  bone.  Then  control  all  bleeding 
points  and  sew  up  carefully  the  resulting  wound.  Take  pains  especially 
to  make  a  close  joint  of  the  severed  mucosa,  for  the  mucous  membranes 
heal  readily  when  properly  approximated. 

As  I  have  stated,  in  doing  this  operation  and  other  extensive  dis- 


THE   TONGUE  569 

sections  about  the  nock  and  face  I  am  accustomed  to  follow  Crile's 
suggestion  of  clamping  previously  and  temporarily  the  common  or 
external  carotid  artery,  using  for  that  purpose  Crile's  well-known  artery 
clamp.  I  have  been  impressed  also  by  the  value  of  Crile's  shock-suit, 
which  I  employ  commonly  when  doing  extensive  operations  about  the 
neck  and  head,  the  patient  being  placed  in  a  modified  Fowler's  position, 
at  an  angle  of  about  45  degress.  In  the  case  of  old  and  feeble  persons 
with  advanced  cardiovascular  disease  these  extensive  excisions  are 
dangerous  and  the  mortality  high,  the  patients  sometimes  dying  within 
a  few  hours  or  lingering  on  for  a  week.  In  the  case  of  such  patients, 
therefore,  the  surgeon  should  approach  the  operations  with  the  greatest 
hesitation.  Younger  and  more  vigorous  persons,  however,  rally 
promptly,  and  often  live  to  enjoy  a  fairly  comfortable  existence,  though 
the  deformity,  especially  in  the  case  of  women,  is  considerable. 

Excision  of  the  entire  lower  jaw  sometimes  must  be  undertaken  in 
cases  of  phosphorus  necrosis,  which  causes  an  almost  total  destruction  of 
the  bone.  The  operation  is  a  mere  extension  and  duplication  of  that  I 
have  described  already ;  or  sometimes  the  bone  may  be  removed  from 
within  the  mouth.  In  any  case  the  periosteum  should  be  preserved  so 
far  as  possible.     Rarely  a  complete  removal  of  the  jaw  is  necessary. 

The  Tongue 

The  tongue  is  probably  the  most  important  organ,  after  the  eye, 
concerned  with  the  special  senses.  Inasmuch  as  its  functions  have  to 
do  with  speech,  taste,  and  deglutition,  any  ailment  or  lesion  of  the  tongue 
becomes  instantly  of  prime  importance  to  the  patient.  The  tongue, 
like  the  heart,  is  an  organ  of  simple  stiiicture,  made  up  almost  entirely  of 
muscles.  It  springs  from  the  hyoid  bone,  is  attached  to  the  lower  jaw, 
and  is  a  much  larger  structure  in  extent  than  casual  inspection  would  in- 
dicate. When  the  physician  ''  looks  at  the  tongue  "  as  part  of  his  routine 
inspection,  he  sees  little  more  than  its  tip  and  the  anterior  quarter  of 
its  dorsum.  Two  sets  of  muscles  compose  the  tongue — such  extrinsic 
muscles  as  the  hyoglossus  and  styloglossus,  which  pull  the  tongue  back, 
and  the  genioglossus,  which  pulls  the  tongiie  f onvard ;  but  the  main  im- 
portant muscle  is  the  lingualis,  which  arises  from  the  hyoid  and  makes 
up  the  greater  part  of  the  tongue's  bulk.  The  hypoglossal  and  chorda 
tympani  nerves  supply  the  tongue  with  innervation,  while  the  most  of 
its  blood  reaches  it  through  the  ling-ual  artery,  which  springs  from  the 
external  carotid.  The  circum vallate  papillae  lie  close  to  the  larynx, 
in  the  root  of  the  tongue,  and  numerous  mucous  glands  cover  the 
dorsum  of  the  organ.  The  mucosa  of  the  dorsum  is  thick  and  rough,  but 
the  mucosa  beneath  the  tip  of  the  tongue  is  extremely  thin  and  cleKcate. 
The  tongue  throughout  is  intersected  by  large  and  frequent  lymph 
radicles.  It  is  a  flexible,  active,  sensitive  member,  but,  fortunately 
for  the  human  race,  it  readity  resists  pathologic  damage,  so  that  in  spite 
of  its  unique  structure  and  exposed  position,  it  is  not  often  diseased. 

The  surgeon  is  interested  especially  in  two  types  of  tongue  lesions — 


\ 


570  THE    FACE    AND    NECK 

inflammations  and  tumors.  There  are  other  abnormalities  of  the  tonjrue 
which  occasionally  one  sees — defoiinities,  the  most  important  of  which 
is  macroglossia — a  <ii<iantic  overgrowth,  which  may  be  due  to  fibro- 
myomatu  or  lymphangiomata,  when  the  tongue  may  become  so  large  as 

to  ])rotrude  from  the  mouth 
and  hang  over  the  chin.  Mac- 
roglossia is  congenital,  and  can 
be  relieved  by  partial  excision 
of  the  organ  only. 

Tongue-tie  (ankyloglossia) 
is  a  congenital  deformity  also, 
and  is  not  very  common.  It 
is  due  to  a  short  frenum,  which 
anchors  the  tip  of  the  tongue 
to  the  floor  of  the  mouth.  Most 
cases  of  tongue-tie  need  no  treat- 
\  ment,  for  the  tongue   develops 

)  normally    as    the    child    grows; 

'  but  if  the  condition  persists,  it 

is  easily  relieved  by  raising  the 
I  ;'  tongue  on  an  elevator  and  snip- 

ping with  a  pair  of  scissors  the 
short  frenum  (that  notched 
spatula,  the  handle  of  an  ordi- 
nary' grooved  director  was  de- 
vised for  this  operation) .  There 
may  be  a  smart  little  hemor- 
rhage after  this  snipping,  but 
this  is  readily  controlled  by 
Fig.  378. — Macroglossia.  allowing   the    patient    at    once 

to  suckle. 
Wounds   and  lacerations  of  the  tongue  are  not   very  common — 
the  most  fi-equent  cause  of  such  lacerations  is  the  patient's  biting  his 
tongue  in  an  epileptic  convulsion.     Such  damage  is  remedied  by  one  or 
two  stitches  after  the  wound  has  been  thoroughly  cleansed. 

INFLAMMATION 
There  are  various  forms  of  inflammation  of  the  tongue,  acute  and 
chronic.  The  former  are  more  common  among  children  and  the  latter 
among  adults.  Acute  inflammations  have  little  interest  for  the  surgeon. 
They  usually  disappear  piomptly  under  the  use  of  bland,  warm  lotions, 
such  as  alum  water,  tincture  of  myrrh,  or  "  alkalol."  The  chronic  in- 
flammations are  much  more  intractable,  and  may  lead  up  to  serious  con- 
ditions; the}^  may  be  the  precursors  of  malignant  disease  even.  The 
term  chronic  glossitis  embraces  these  various  inflammatory  changes, 
the  important  characteristic  of  which  is  a  change  of  form,  an  over- 
growth of  the  epidermis,  keratosis.  Bland-Sutton  ^  has  pointed  out 
^  J.  Bland-Sutton,  Tumors,  Innocent  and  Malignant,  fourth  ed.,  1907,  p.  333. 


CANCER  571 

that  in  a  fair  proportion  of  cases  cancer  of  tho  tongue  is  preceded  h)y 
the  changes  known  as  leukoplakia  and  ichthyosis.  Leukoplakia  and 
iclithyotic  patches  are  tlie  names  given  to  chronic  white  areas  on  the 
tongue  and  nuu'osa  of  the  cheeks,  the  result  of  keratosis.  Many 
observers  believe  that  gouty  conditions,  syphilis,  and  excessive  smoking 
are  the  usual  causes  of  leukoplakia.  The  patient  discovers  the  leuko- 
])lakia  by  accident,  but  later  is  troubled  by  stiffness  of  the  tongue  and 
impairment  of  the  sense  of  taste.  The  outlook  for  leukoplakia  is  not 
especially  encouraging,  but  improvement  may  be  looked  for  under  the 
use  of  alkaline  washes,  abstinence  from  irritating  foods,  tobacco,  and 
alcohol,  and  the  employment  of  appropriate  syphilitic  remedies.  Ich- 
thyotic  patches  do  not  necessarily  become  cancei'ous  in  every  individual, 
so  that  after  excision  of  a  cancerous  tongue  even  the  stump  may  become 
ichthyotic  and  the  disease  not  recur  in  it. 

Tuberculosis  of  the  tongue  is  a  rare  form  of  chronic  ulceration,  a 
condition  not  always  easy  to  determine,  but  it  should  be  differentiated 
from  syphilis  and  cancer.  Tuberculosis  appears  as  a  red,  sloughing, 
superficial  ulcer,  usually  on  the  dorsum  of  the  tongue,  sometimes  as- 
sociated with  pulmonary  tuberculosis,  sometimes  primary.  In  either 
case,  if  the  diagnosis  of  tuberculosis  be  made — by  the  microscope — the 
ulcer  should  be  excised. 

Abscess  of  the  tongue  is  a  very  rare  condition  also,  and  is  due  gen- 
erally to  the  breaking  dow^n  of  a  gumma.  Situated  in  the  median  line 
of  the  tongue,  it  takes  on  a  chronic  course  and  appears  as  a  deep  elastic 
swelling  which  should  be  opened  and  cureted,  while  at  the  same  time 
the  patient  should  be  put  upon  proper  doses  of  potassium  iodid. 

Turning  back  now  to  those  forms  of  chronic  glossitis  characterized 
by  leukoplakia,  we  see  in  a  certain  proportion  of  cases  that  the  con- 
dition runs  into  cancer. 

CANCER 

Carcinoma  of  the  tongue,  like  carcinoma  of  the  lips,  ears,  and  buccal 
mucosa,  is  of  the  squamous-cell  type.  It  may  be  called  truly  a  dread- 
ful disease,  for  it  destroys  life  quickly,  and  while  it  lasts  it  renders  the 
patient  a  loathsome  object.  I  know  no  form  of  cancer  fouler  or  more 
offensive.  Cancer  of  the  tongue  must  be  distinguished  always  from 
syphilis  and  from,  tuberculosis,  but  the  diagnosis  is  not  especially  diffi- 
cult and  should  be  confirmed  by  the  microscope.  Cancer  begins  com- 
monly on  the  edges  or  tip  of  the  tongue;  the  lesions  of  syphilis  and  tuber- 
culosis are  more  common  in  the  tongue's  center.  Cancer  of  the  tongue 
spreads  rapidly  by  direct  continuity  or  along  the  lymphatic  vessels. 
Metastatic  growths  in  the  internal  viscera  or  long  bones  are  extremely 
rare.  It  is  hard  to  say  just  how  early  in  cancer  of  the  tongue  the  lymph 
nodes  become  affected,  but  it  is  probable  that  they  are  involved  within 
the  early  months,  and  for  this  reason  the  surgeon  should  know  the 
commoner  sites  of  the  nodes  involved.  One  must  have  in  mind  the  fact 
that  the  enlarged  nodes  are  found  in  a  variety  of  places — the  submaxil- 
lary nodes,  which  receive  the  drainage  from  the  lower  surface,  the  middle, 


572  THE    FACE    AND    NECK 

and  dorsum  of  the  tongue  and  the  entire  floor  of  the  mouth ;  the  superior 
and  inferior  deep  cervical  nodes,  which  receive  the  drainage  from  the 
entire  tongue  and  the  floor  of  the  mouth;  and  those  intramuscular  nodes 
situateH^in  the  geniohyoid  muscles,  which  receive  the  drainage  from  the 
floor  of  the  mouth  and  lower  surface  of  the  tongue.  Moreover,  nodes  in 
the  parotid  region  may  be  involved  through  retrograde  lym})h-currents. 
But  the  problem  of  lymphatic  invasion  is  still  more  comj)licated,  because, 
through  the  intercommunication  of  lymphatics,  cancer  of  one  side  of  the 
tongue  may  involve  the  lymph-nodes  of  both  sides  of  the  neck.  The 
most  important  nodes  perhaps  are  those  situated  at  the  bifurcation  of 
the  common  carotid  artery.  One  sees,  therefore,  that  in  order  thoroughly 
to  remove  all  possibly  involved  nodes,  it  may  be  necessary  to  dissect 
both  sides  of  the  neck  and  frequently  the  lower  part  of  the  parotid.^ 

The  course  of  cancer  of  the  tongue  is  distressing  from  the  outset,  and 
toward  the  end  may  become  extremely  painful.  The  ulceration  may 
not  be  very  extensive,  but  it  is  sore  and  foul,  while  it  is  characteristic 
of  cancer  of  the  tongue  that  the  lymph-nodes  involved  may  become 
enormous — out  of  all  apparent  proportion  to  the  size  of  the  primary 
growth.  Death,  which  comes  within  fourteen  months  often,  is  due  not 
sojnuch  to'the  original  cancer,  as  to  the  extensive  involvement  of  the 
nodes  w^hich  press  upon  the  trachea  and  esophagus  and  implicate  rap- 
idly all  the  great  structures  of  the  neck.  The  end  of  these  patients  is 
miserable :  secondary  developments  often  follow  the  most  radical  opera- 
tions, and  morphin  alone  remains  to  alleviate  and  cut  short  a  wretched 
existence.  For  this  reason  surgeons  welcome  all  endeavors  to  eradicate 
the  primary  disease,  and  recent  extensive  mutilating  operations  have 
been  accepted  with  approval,  while  such  statistics  as  those  of  Crile 
give  us  cause  for  a  genuine  optimism. 

Operations  for  cancer  of  the  tongue  may  be  divided  properly  into 
two  classes — those  for  the  less  advanced  cases  and  those  for  the  more 
advanced  cases.  In  describing  operations  for  cancer  of  the  lip  I  recalled 
tTTe  familiar  analogy  between  breast  cancer  and  face  cancer,  and  pointed 
out  that  the  necessity  for  excision  of  lymph-nodes  is  equal  in  both. 

In  the  case  of  early  tongue  cancer  one  sees  that  the  amount  of  tissue 
to  be  removed  depends  upon  the  extent  of  the  lesion,  but  in  all  cases  I 
believe  that  a  dissection  should  be  made  of  the  deep  parts  of  the  neck, 
as  w^e  dissect  the  axilla  in  cases  of  early  breast  cancer.  If  the  initial 
growth  is  minute  and  on  the  anterior  part  of  the  tongue,  one  should 
remove  the  little  tumor  with  a  wide  margin,  taking  in  tissue  somewhat 
beyond  the  median  line ;  but  if  the  tumor  is  well  established,  especially 
if  it  be  encroaching  upon  the  posterior  parts  of  the  tongue,  that  organ 
should  be  removed  entire,  and  a  deep  dissection  from  the  clavicles  up 
should  be  made  of  both  sides  of  the  neck,  as  I  described  it  in  discussing 
cancer  of  the  lip. 

Various  methods  of  removing  the  tongue  have  exercised  the  ingenuity 
of  surgeons,  and  the  books  discuss  the  operations  of  Whitehead,  Kocher, 

'  D.  N.  Eisendrath,  A  Plea  for  More  Radical  Operations  in  Cancer  of  the  Lips  and 
Tongue,  Jour.  Amer.  Med.  Assoc,  September  29,  1906. 


CANCER 


573 


Billroth,  and  others.  Any  method  is  satisfactory  for  the  practical  sur- 
geon so  long  as  he  removes  the  entire  tongue,  but  the  proper  dissection 
of  the  neck  is  a  matter  of  primary  importance.  Whitehead  removes  the 
tongue  with  scissors  through  the  mouth.  He  passes  a  ligature  through 
the  tip  and  draws  it  well  forward,  dissects  up  the  organ  from  the  floor 
of  the  mouth,  and  divides  the  anterior  pillars  of  the  fauces.  He  then  se- 
cures the  lingual  arteries;  passes  a  second  ligature  through  the  giosso- 
epigiottidean  fold,  below  the  point  of  transverse  section,  to  secure  the 
stump  and  draw  it  forward,  and  then  completes  the  extirpation.  The 
parts  are  then  thoroughly  cleansed  and  painted  with  an  antiseptic 
varnish.^     The  patient  is  fed  freely  from  the  second  day.     The  ligature 


Fig.  379. — Whitehead's  operation  for  cancer  of  the  tongue. 


at  the  base  of  the  tongue  is  either  fastened  to  the  teeth  or  kept  hanging 
out  of  the  mouth  by  a  pair  of  forceps,  so  as  to  prevent  the  stump  from 
falling  backward  over  the  glottis.  This  ligature  usually  can  be  re- 
moved at  the  end  of  forty-eight  hours. 

Of  the  other  operations  for  the  removal  of  the  tongue,  I  prefer  jiid 
employ  commonly  one  which  consists  in  splitting  down  the  cheek  from 
the  corner  of  the  mouth,  dividing  the  jaw  with  a  saw,  and  so  laying 
broadly  open  the  mouth  and  pharynx.  Through  this  same  incision  the 
external  carotid  artery  may  be  controlled,  so  that  the  operation  may  be 

1  Compound  tincture  of  benzoin,  combined  with  an  equal  amount  of  saturated 
ethereal  solution  of  iodoform. 


574  THK    FACE    AND    NF.CK 

performed  without  hemoirhage.  After  the  tongue  has  been  removed, 
the  severed  jaws  should  be  wired  and  the  soft  parts  carefully  read- 
justed.    The  resulting  scar  is  slight. 

The  after-treatment  following  complete  excision  of  the  tongue  is  ex- 
tremely Importaiit,  since  these  patients  may  die  shortly  of  septicemia, 
septic  pneumonia,  or  exhaustion.  In  simple  cases  even,  the  immediate 
mortality  record  of  some  operators  i-uns  up  as  high  as  "25^per  cent. 
The" after-treatment  consists  in  inforcing  cleanliness.'  It  is  well  to 
dust  the  floor  of  the  mouth  daily  with  iodoform  and  keep  the  jiavity 
washed  with  some  antiseptic  lotion,  of  which  carbolic  acid  is  as  good 
as  any.  The  ]3atient  should  have  the  services  of  two  nurses,  who 
should  wash  out  the  mouth  at  least  once  an  hour  during  the  first  two 
days.  Saliva  collects  rapidly  and  mingles  with  the  other  discharges, 
so  that  the  surgeon  should  provide  aclequate  drainage  by  a  drainage- 
tube  led  out  through  a  drainage  opening  in  the  neck.  Proper  feed- 
ing to  support  the  patient's  strength  is  of  primary  imi)ortance.  For 
the  first  twenty-four  hours  nutrient  enemata  suffice,  but  general!}', 
after  that,  the  patient  can  swallow  liquids,  and  if  not,  he  may  be  fed 
througli  a  stomach-tube.  Do  not  make  an  invalid  of  one  of  these  pa- 
tients. Get  him  up  on  the  second  day,  keep  him  out-of-doors,  and  en- 
courage him  with  the  reasonable  prospect  of  being  able  to  go  home 
within  two  weeks.  At  the  best  this  treatment  is  difficult,  but  it  is  essen- 
tial and  must  be  persisted  in  until  the  patient  has  learned  comfortably 
to  manage  the  toilet  of  his  mouth  and  the  taking  of  food. 

SARCOMA  OF  THE  TONGUE 

Some  40  cases  of  sarcoma  of  the  tongue  have  been  reported,  so  one 
sees  that  sarcoma  of  this  organ  is  a  rare  disease.  Sarcoma  is  b\-  no 
means  as  malignant  as  cancer  of  the  tongue.  It  kills  slowly  and  through 
distant  metastases.  Most  of  these  sarcomata  are  primary  tumors  of 
the  round-cell  variety.  Ulceration  is  uncommon,  and  the  patient 
may  live  more  than  two  years  after  the  onset  of  the  disease.  The  sur- 
geon should  employ  the  same  radical  treatment  as  in  the  case  of  cancer 
of  the  tongue. 

Rarely  one  sees  non-malignant  tumors  of  the  tongiie.  A  few  tumors 
of  embryonfc  origin  are  reported,  as  well  as  lipomata,  fibromata,  and 
cartilaginous  and  bony  tumors.  These  growths  readily  may  be  removed 
locally  by  enucleation.  The  commonest  non-malignant  swellings  are  the 
angiomata,  which  may  be  treated  by  the  cautery,  by  radical  excision,  by 
the  application  of  carbon -dioxid  snow,  or  by  the  injection  of  boiling 
water.  My  own  preference  is  for  carbon-dioxid  snow,  which  is  almost 
always  effective;  it  is  little  mutilating  and  causes  the  patient  very  slight 
discomfort. 

The  Salivary  Glands 

The  salivary  glands  are  subject  to  sundry  surgical  diseases — to 
tumors  especially.     Chondroma  is  probably  the  most  common  of  these 


THE   SALIVAR\    GLANDS 


575 


tumors.  Chondroma  occurs  in  the  parotid  gland,  because  the  first 
branchial  arch  lies  at  the  site  of  the  parotid,  and  fetal  cartilaginous 
structures  become  included  during  the  gland's  growth.  In  the  same 
way  cartilage  of  the  second  branchial  arch  becomes  included  in  the 
submaxillary  gland.  These  gland  tumors  appear  as  globular,  nodular 
masses,  of  slow  and  painless  growth,  although  late  they  may  become 
converted  into  adcnosarcomata  and  progress  rapidly.  Parotid  chon- 
droma is  important  because  it  produces  deformity  and  may  involve  the 
branches  of  the  seventh  cranial  nerve  with  a  resulting  facial  paralysis. 
These  chondromata  must  be  distinguished  from  sarcomata,  which  appear 
quite  like  the  chondromata,  but  are  somewhat  more  elastic.  Such  sar- 
comata are  spindle-celled;  they  involve  neighboring  structures,  espe- 
cially the  skin,  facial  nerve,  and  pharynx,  and  should  be  removed  as 
soon  as  suspected. 


Fig.  380. — Sketch  showing  line  for  total  excision  of  parotid  gland. 

A  chondroma  of  the  parotid  gland  generally  can  be  shelled  out 
without  much  trouble,  but  in  the  operation  the  surgeon  should  take  pains 
not  to  damage  the  facial  nerve.  Sometimes  a  salivary  fistula  follows. 
It  usually  closes  of  itself.  Sometimes  it  is  necessary,  in  the  case  of 
malignant  tumors,  to  remove  the  whole  gland,  a  difficult  operation,  the 
steps  of  which  are  well  described  by  Binnie,^  somewhat  as  follows: 
make  a  T-shaped  (or  crescent-shaped)  incision  through  the  skin,  and 
turn  back  the  flap ;  loosen  up  the  anterior  edge  of  the  gland  and  secure 
the  vessels  and  Steno's  duct;  peel  back  the  gland  from  underlying  stmc- 
tures  at  its  top  and  bottom;  expose  the  upper  end  of  the  sternomastoid 
muscle,  open  its  sheath,  and  retract  the  muscle  backward;  then,  working 
from  above,  wdth  blunt  dissection  lay  bare  the  external  carotid  arter}-, 
which  you  may  or  may  not  tie,  and  free  the  tumor  with  the  gland  up 
to  the  level  of  the  styloid  process.  The  remainder  of  the  operation 
^  J.  F.  Binnie,  Manual  of  Operative  Surgery,  third  ed.,  p.  146. 


576  THE    FACE    AND    NECK 

consists  in  separating  carefully  the  gland  fi-oni  all  deep  structures,  tying 
the  vessels  as  one  ])roceeds.  In  closing  the  wound  the  sui-geon  should 
provide  carefully  for  drainage,  and  should  look  for  a  complete  facial 
paralysis  on  the  affected  side,  a  condition  which  may  he  remedied,  if 
thought  best,  by  a  faciospinal-accessory  anastomosis. 

Pharynx  and  Nasopharynx 

Diseases  of  the  pharynx  antl  nasopharynx  fall  so  distinctly  within 
the  field  of  a  throat  specialist's  work  that  I  shall  not  consider  them  in 
detail.  There  are,  however,  certain  tumors  and  other  lesions  of  these 
regions  which  the  general  surgeori  frequently  and  pro]iei-ly  is  called  upon 
to  treat.  I  need  but  mention  the  great  tonsils  of  inflammatory  origin 
which  block  the  throat  and  interfere  wth  proper  breathing  and  swallow- 
ing. I  am  aware  that  any  general  surgeon  can  easily  remove  these 
masses,  but  I  am  convinced  that  such  surgery  should  be  left  to 
throat  specialists,  because  not  only  is  their  judgment  superior  regarding 
the  treatment  of  individual  cases  and  their  technic  more  effective,  but 
they  can  much  more  satisfactorily  deal  with  the  adenoids,  nasal  spurs, 
and  middle-ear  disease  which  commonly  are  associated  with  chronic 
inflammatory  processes  in  the  throat.  I  deprecate  the  treatment  of 
these  s|)ecial  lesions  by  general  surgeons. 

Malignant  tumors  of  the  tonsil  are  not  uncommon.  Sarcoma  alone 
is  primary  there,  Avhile  tonsillar  carcinoma  is  an  extension  from  a  focus 
in  the  mouth.  The  diagnosis  of  sarcoma  of  the  tonsil  is  not  always  easy. 
The  patient  complains  of  sore  throat  and  debility.  The  surgeon  exam- 
ines the  throat  and  finds  a  lai'ge,  smooth  tonsil,  harder  than  an  ordinaiy 
inflammatory  swelling.  He  may  mistake  this  for  an  inflamed  tonsil, 
but  if  he  attempts  to  remove  it,  its  infiltrating  nature  and  the  sharp  ob- 
stinate hemorrhage  which  results  from  cutting  will  show  him  his  mistake. 
The  cautious  operator  will  have  taken  a  bit  of  tissue  from  the  suspected 
mass,  and  by  the  microscope  will  have  confirmed  the  diagnosis  of  sar- 
coma. 

The  removal  of  such  a  malignant  tonsil  is  far  more  of  an  undertaking 
than  the  removal  of  a  hypertrophied  tonsil.  Commonly,  the  operation 
is  called  pharyngectomy,  though  properly  it  should  be  called  tonsil- 
lectomy. 

Extirpation  of  malignant  disease  of  the  tonsil  cannot  properly  be  done 
through  the  normal  opening  of  the  mouth.  The  surgeon  must  secure 
some  wider  avenue  of  approach,  and  various  methods  of  approach 
through  the  neck  or  mouth  have  been  advocated.  My  own  preference 
is  to  enlarge  the  mouth-opening  and  saw  through  the  lower  jaw,  as  prac- 
tised by  J.  C.  Warren  and  others.  One  is  enabled  thus  to  work  in  a  broad 
field  and  with  a  satisfactory  view  of  the  offending  tonsil.  The  illus- 
tration (Fig.  381)  shows  how,  in  enlarging  the  mouth  opening,  the  cut 
is  carried  down  from  the  angle  of  the  mouth  obli(iuely  to  the  middle  of 
the  body  of  the  jaw.  This  is  done  with  one  firm,  deep  stroke,  severing 
the  skin,  muscles,  mucosa,  and  facial  vessels.     The  operator  then  saws 


PHARYNX    AND   NASOPHARYNX  577 

through  the  jaw,  and  with  retractors  separates  widely  the  divided  parts. 
When  he  attacks  the  growth  proper,  he  should  do  so  freely  and  boldly, 
removing  the  tumor  with  a  wide  margin.  The  large  lent  in  the  back  of 
the  pharynx  cannot  be  closed  with  sutures,  but  must  be  left  to  granulate, 
so  that  during  the  convalescence  somewhat  the  same  care  must  be  em- 
ployed as  after  excision  of  the  tongue.  A  temporary  clamp  on  the  com- 
mon carotid  will  be  a  great  comfort  to  the  surgeon  in  doing  this  some- 
what hazardous  operation.  The  severed  jaw  should  be  united  at  once 
with  silver  wire,  the  mucosa  carefully  stitched  with  catgut,  and  the  skin 
wound  united.  The  healing  is  rapid  and  satisfactory,  the  resulting  ex- 
ternal scar  is  slight,  and  the  patient  is  able  to  be  about  within  two  or 
three  days  after  the  operation. 


% 


Fig.  381. — Method  of  approaching  the  fauces.     Line  of  incision. 

There  are  certain  other  interesting  lesions  of  the  pharynx,  though 
few  of  them  fall  within  the  purview  of  the  general  surgeon.  Adenoids 
of  the  nasopharynx  should  be  left  to  the  throat  specialist,  as  should  the 
simple  inflammatory  processes — tonsillitis  and  peritonsillar  abscess. 
Small  foreign  bodies,  such  as  fish-bones  in  the  throat,  may  cause  ex- 
quisite discomfort,  and  the  patient  will  tell  you  that  they  are  "  stuck  in 
the  throat."  It  is  the  fashion  with  many  practitioners  to  assume  that 
the  fish-bone  is  not  so  stuck,  but  that  its  passage  has  caused  an  irritation. 
In  many  of  these  cases,  however,  on  careful  searching  with  reflected 
light  and  the  finger,  you  will  discover  the  tip  of  the  bone  projecting  from 
one  of  the  tonsils  in  which  it  is  buried.  Remove  it  with  a  pair  of  long 
forceps. 

"  Choked  to  death  "  is  a  common  phrase,  and  appears  as  a  scare 
headline  in  the  newspapers.     Sometimes  the  statement  is  true.     The 

37 


578  THE    FACE    AND    NECK 

victim,  in  bolting  a  hasty  meal,  involuntarily  deposits  a  large  bolus  of 
meat  or  other  food  in  the  depths  of  the  pharynx,  where  it  becomes 
wedged  over  the  glottis.  Air  is  cut  off,  the  patient  gasps,  struggles, 
turns  blue,  and  dies  very  quickly.  The  tragedy  is  so  sudden,  and  the 
catastrophe  so  final,  that  rarely  can  medical  aid  be  called  in  time  to  be 
of  service.  Sometimes,  however,  the  glottis  is  not  completely  obstructed 
and  the  patient  struggles  on  in  terror  and  distress  for  minutes  or  even 
hours.  The  surgeon,  if  called  in  time,  detects  the  offending  bolus  with 
his  finger  or  by  the  head-mirror,  and  removes  it  with  a  long  curved 
forceps.  At  a  pinch,  if  other  means  fail,  a  hypodermic  of  apomorphin 
will  induce  violent  vomiting  and  expulsion  of  the  foreign  body. 

Sometimes  the  surgeon  is  called  upon  to  treat  burns  and  scalds 
of  the  tongue,  pharynx,  glottis,  and  epiglottis.  The  patient  may  have 
swallowed  a  boiling  fluid  or,  if  a  fireman,  may  have  inhaled  flame  or 
steam.  The  immediate  result  of  such  burns  is  horribly  distressing. 
Intense  congestion  ensues,  with  blistering  and  edema.  If  the  air- 
passages  remain  open,  the  surgeon  can  do  no  more  than  attempt  to  re- 
lieve the  distress  by  feeding  bits  of  cracked  ice  and  applying  cocain. 
If  edema  threatens  to  close  the  glottis,  the  surgeon  must  intubate  the 
larynx  or  perform  tracheotomy, 

DISEASES  OF  THE   LARYNX 

Diseases  of  the  larynx  are  closely  associated  in  their  causation 
and  therapeutics  with  diseases  of  the  pharynx  and  nasal  passages,  and 
their  treatment  falls  generally  to  the  laryngologist.  As  in  the  case  of 
the  pharynx,  however,  there  are  certain  laryngeal  ailments  which  the 
general  surgeon  must  be  prepared  to  treat.  The  anatomy  and  mechan- 
ism of  all  these  parts  are  extremely  intricate  and  difficult  of  comprehen- 
sion. The  musculature  and  innervation  are  curiously  involved,  and 
the  functions  of  the  structures  intimately  interdependent.  Hearing, 
smell,  speech,  breathing,  and  deglutition  form  a  curious  complex,  there- 
fore, worthy  the  exclusive  stutly  of  a  specialist,  and  the  rash  tampering 
with  these  organs  by  the  inexpert  is  reprehensible.  Some  few  grave 
accidents  or  ailments  of  the  larynx,  however,  do  fall  to  the  general 
surgeon — cut-throats,  fractures  of  the  hyoid  bone  and  thjToid  cartil- 
ages, and  tumors  of  the  lar}-nx,  while  the  surgeon  should  be  prepared 
also  to  perform  the  operations  of  intubation  and  tracheotomy. 

Cut-throat  is  a  bugbear  of  fiction,  especially  the  throat  cut  from 
"  ear  to  ear."  Ordinarily,  a  cut  throat  implies  little  more  than  a  skin 
wound,  though  the  "  ear-to-ear"  cut-throat  conceivably  may  open  the 
pharynx.  These  superficial  wounds  are  easily  repaired  with  stitches, 
and  the  patient  usually  recovers.  The  dangerous  cut-throat  is  that 
low  in  the  neck,  at  the  level  of  or  beneath  the  thyroid  cartilage.  This 
wound  even  must  be  so  deep  as  almost  to  reach  the  vertebral  column  if 
the  result  is  to  be  immediately  fatal.  A  mere  opening  of  the  larynx  or 
trachea  will  not  kill  the  victim  necessarily;  to  kill,  the  weapon  must 
search  out  and  sever  the  carotid,  or  jugular  vessels  or  the  pneumo- 


DISEASES   OF   THE    LARYNX  579 

gastric  nerves.  An  opened  win(l})i])e  nuiy  be  sewed  up,  with  a  resulting 
recovery,  though  the  ijutient  luns  the  risk  of  a  subsequent  inhalation 
pneumonia;  but  he  almost  always  dies  promptly  if  the  deeper  structures 
are  injured. 

Sometimes  a  sharp  blow  on  the  front  of  the  neck  will  fracture  the 
hyoid  bone  or  the  thyroid  cartilages,  and  serious  results  may  ensue. 
The  fracture  fretiuently  is  complicated  by  laceration  of  the  mucosa, 
b}'  hemorrhage,  and  by  obstruction  of  the  air-passages  through  hemato- 
mata  and  edema.  The  immediate  danger,  therefore,  is  suffocation; 
the  more  remote  danger  is  an  inhalation  pneumonia,  so  that  prompt  and 
radical  treatment  is  imperative. 

Treatment. — Fracture  of  the  hyoid  rarely  is  not  very  serious.  The 
damaged  bone  may  be  supported  by  strappings  about  the  neck,  and  heal- 
ing may  take  place  without  special  further  annoyance;  but  damage  to 
the  thyroid  cartilage  is  a  more  important  matter.  It  may  be  necessary 
to  perform  tracheotomy  in  order  to  secure  proper  air-space,  after  which 
the  injured  larynx  may  be  repaired  at  the  surgeon's  leisure.  A  safe, 
useful,  and  generally  successful  operation  consists  in  splitting  open 
carefully  the  larynx  in  the  median  line,  replacing  the  dislocated  frag- 
ments, and  sewing  up  tightly  the  wound,  or  in  establishing  suitable  drain- 
age if  the  exudate  be  considerable.  The  breathing  and  speaking  func- 
tions generally  will  be  restored,  unless  there  be  damage  to  the  recurrent 
laryngeal  nerves. 

A  somewhat  frequent,  distressing,  and  serious  accident  is  the  pas- 
sage of  a  foreign  body  into  the  larynx  and  trachea,  and  these  foreign 
bodies  ma)^  be  of  great  variety^pins,  bristles,  tin  whistles,  buttons, 
and  the  like,  D.  W.  Cheever  describes  a  case  in  which  a  single  bristle 
from  a  beard  of  wheat  was  inhaled  into  the  trachea,  and  without  becom- 
ing impacted,  played  up  and  down  the  windpipe  until  removed  through- 
a  tracheotomy  opening.  The  lighter  and  pointed  foreign  bodies  may 
become  engaged  anywhere  in  the  air-passages,  penetrating  to  the  bronchi 
even;  while  the  more  solid  bodies,  when  inhaled,  sink  at  once  into  the 
chest.  In  Chapter  XVI,  I  have  described  the  present  ingenious  methods 
of  removing  such  foreign  bodies  through  the  bronchoscope  inserted 
through  the  mouth  or  through  a  tracheotomy  opening. 

I  have  referred  frequently  in  this  chapter  to  intubation  and  tracheot- 
omy, useful  operations  employed  to  facilitate  respiration  in  the  event  of 
laryngeal  or  tracheal  obstruction.  Let  us  for  a  moment  rehearse  the 
details  of  these  two  operations  before  taking  up  a  description  of  tumors 
of  the  larynx,  the  most  important  laryngeal  diseases  with  which  the 
surgeon  has  to  deal. 

Intubation  of  the  larynx  signifies  passing  a  breathing-tube  between 
the  vocal  cords.  The  operation  is  performed  commonly  for  membran- 
ous obstmction  due  to  diphtheria,  but  occasionally  the  surgeon  may  find 
it  useful  under  other  circumstances.  A  special  set  of  instruments 
(O'Dwyer)  is  required,  as  pictured  in  the  illustration:  (1)  Tubes  with  ob- 
turators adapted  to  the  patient's  age ;  (2)  a  gauge  to  aid  in  the  selection 
of  the  proper  tube;  (3)  mouth-gag;  (4)  tube  introducer;  (5)  tube  ex- 


580 


THE   FACE   AND    NECK 


tractor.  The  operation  is  simple  enough,  and  the  surgeon  performs  it 
somewhat  as  follows:  with  the  patient  held  upright  and  the  jaws  forced 
widely  open,  the  surgeon  attaches  the  proper  tul)e  to  the  introducer,  a 
piece  of  thread  being  fastened  to  the  tube  at  the  same  time  and  tied 
to  the  surgeon's  finger,  so  that  he  may  jerk  out  the  tube  quickly  if  neces- 
sary. He  then  holds  his  instrument  in  his  right  hand,  seeks  the  tip  of 
the  epiglottis  with  the  left  index-finger,  raises  the  epiglottis,  and  passes 
the  tube  quickly  into  the  larynx,  the  left  index-finger  preventing  it,  as 
it  passes,  from  falling  into  the  esophagus.  If  the  tube  is  properly  ])laced, 
the  patient's  breathing  is  relieved  at  once.     \A'hen  the  time  comes  for 


Fig.  382. — O'Dwyer's  intubation  instruments:  A,  Tube  with  ol)turator;  B, 
tube;  C,  obturator;  D,  metal  gauge;  E,  mouth-gag;  F,  introducer;  G,  extractor;  H, 
silk  cord  (Fowler). 


removing  the  tube,  that  operation  is  readily  performed  with  the  ex- 
tractor and  by  a  maneuver  quite  similar  to  the  method  of  introduction. 
Tracheotomy  is  one  of  the  ancient  operations  of  surgery.  In  former 
days  it  was  resorted  to  for  the  removal  of  foreign  bodies  from  the  air- 
passages,  and  for  centuries  it  was  employed  for  no  other  purpose. 
Strangely  enough,  the  older  surgeons  and  physicians  do  not  seem  to 
have  appreciated  that  opening  the  larynx  or  trachea  is  the  proper 
measure  for  the  relief  of  suffocation  due  to  laryngeal  obstruction. 
Probably  the  most  eminent  life  sacrificed  unnecessarily  through  the 
neglect  of  tracheotomy  was  that  of  George  Washington.  According  to 
F.  H.  Hooper,  the  immediate  cause  of  Washington's  death  was  edema 


DISEASES   OF   THE    LARYNX 


581 


of  the  larynx,  and  there  is  no  doubt  that  a  timely  tracheotomy  would 
have  saved  the  Datient.  Hooper  adds  in  a  note, ' '  1  doubt  if  tracheotomy 
had  ever  been  performed  in  Virginia  in  Washington's  time."  The 
surgeon  responsible  for  this  negligence  was  Craik,  an  excellent^  and 
faithful  practitioner  and  a  warm  personal  friend  of  his  distinguished 
patient.' 

The  operations  of  tracheotomy  and  laryngotomy  are  quite  similar  m 
their  performance.  The  former  signifies  opening  the  windpipe  below 
the  cricoid;  the  latter,  opening  the  windpipe  through  the  cricothyroid 
membrane  or  even  higher.  Elaborate  descriptions  are  given  of  these 
operations,  but,  indeed,  their  performance  is  simple  enough.  The  purpose 
is  to  put  a  curved  tube  into  the  windpipe.  Every  modern  surgeon  in  a 
hasty  emegency  has  opened  the  windpipe  with  a  single  stroke  of  the  knife 
and  inserted  a  tube,  and  this  almost  suffices  for  a  description.     If  more 


Fig.  383.— Intubating  the  larynx  (Lejars). 

time  be  given,  the  surgeon  performs  either  the  high  or  low  operation, 
for  both  of  which  the  same  description  answers.  The  patient  should  be 
placed  in  a  good  light,  with  the  head  somewhat  elevated  and  fully  ex- 
tended, so  as  to  put  the  trachea  on  the  stretch.  A  general  anesthetic 
or  cocain  may  be  employed.  The  skin  is  incised  for  two  or  three  mches 
in  the  median  line,  the  muscles  and  fascia  are  divided,  the  windpipe 
fully  exposed  by  blunt  dissection,  disregarding  the  thyroid  isthmus,  the 
trachea  is  caught  and  steadied  with  a  sharp  hook  and  opened  carefully 
with  a  knife— carefully  so  as  not  to  wound  the  posterior  wall  of  the 
trachea.  The  tracheal  opening  is  then  distended  with  forceps  or  a 
trivalve  dilator,  and  the  tracheotomy  canula  is  introduced.  Cohen's 
tracheotomy  tubes  are  those  commonly  used.  The  complete  tube  (m- 
ner  and  outer)  is  inserted,  the  inner  tube  withdra^\Ti,  and  the  instrument 
secured  in  place  with  tapes  passed  about  the  neck.  A  moist  sponge 
1  Henry  Cabot  Lodge,  George  Washington,  vol.  ii,  p.  296. 


.582 


THE    FACE    AND    NECK 


or  gauze  pad  should  be  fastened,  as  an  air-filter,  over  the  mouth  of  the 
tube.  The  skin  wound  should  be  closed  and  carefully  drc>ssed  and,  as  a 
rule,  the  tracheotomy  tube  should  be  removed  permanently  as  early 


Fig.  384. — Intubating  the  laiynx  (Lejars). 

as  possible.     The  care  of  one  of  these  patients  after  tracheotomy  is  a 
somewhat  delicate  and  important  matter.     During  the  first  hours  a  nurse 


Fig.  385. — Intubating  the  larynx  (Lejars). 

should  attend  constantly  to  the  tube,  seeing  that  it  is  not  plugged  and 
that  the  patient  breathes  comfortably,  attending  to  the  condition  of  the 
sponge,  and  keeping  the  temperature  of  the  room  at  about  80°  F,     It 


DISEASES   OF   THE    LARYNX 


583 


is  an  unfortunate  fact  that  these  wounds  frequently  become  infected, 
either  from  the  skin  or  the  tracheal  mucosa.  Special  care  in  cleanliness 
is,  therefore,  required  lest  the  patient  contract  an  inhalation  pneumonia. 

In  certain  cases  a  more  radical  opening  of  the  trachea  than  that  I 
have  described  becomes  necessary — an  opening  which  shall  cut  off  per- 
manently and  entirely  the  trachea  from  the  upper  air-passages.  To  this 
end  the  trachea  is  amputated  completely  at  the  selected  point,  the  stump 
drawn  forward,  and  its  whole  circumference  stitched  carefully  to  the  skin. 
In  this  case,  if  a  flattening  of  the  trachea  does  not  result,  a  tracheotomy 
tube  is  needless,  for  air  should  pass  freely  into  the  open  trachea.  After 
these  preliminarj-  considerations  let  us 
now  turn  to  the  difficult  subject  of — 

Tumors  of  the  Larynx. — For  the 
general  surgeon  malignant  disease  of 
the  larynx,  necessitating  removal  of 
that  organ,  is  the  onlj'  tumor  of  in- 
terest. Other  neoplasms  there  are — 
papillomas  and  fibromas  and  others — 
which  the  lar}Tigologist  removes  by 
an  internal  operation.  Sarcoma  of  the 
lar}-nx  is  rare,  and  when  it  does  occur, 
springs  from  the  lateral  wall,  but — 

Cancer  of  the  larynx  is  the  most  im- 
portant malignant  growth  found  in  this 
organ.  It  may  be  primary  or  secondary. 
When  secondary,  it  is  an  extension  of  the 
disease  from  the  tong-ue,  jaws,  or  gullet, 
and  its  removal  under  these  circumstances  is  impossible  or  futile. 
Primary  cancer  of  the  larynx  must  engage  our  present  attention. 
Primary  cancer  is  divided  by  Krishaber  into  two  classes — the  intmisic 
form,  beginning  in  the  vocal  cords,  the  ventricular  bands,  or  the  parts 
below;  and  the  extrinsic  form,  starting  in  the  epiglottis,  the  arytenoids, 
or  other  parts  outside  of  the  larynx  proper;  and  this  classification  is  now 
commonly  accepted  by  surgeons.  Intrinsic  cancer  is  papillomatous  in 
character,  warty  in  appearance,  slow  in  growth,  and  associated  rarely  with 
lymphatic  involvements.  The  extrinsic  form,  on  the  other  hand,  grows 
rapidly  and  early  extends  through  the  lymphatic  channels.  The  reader 
■wiU  see  at  once,  therefore,  that  the  two  forms  present  quite  distinct  prob- 
lems. The  intrinsic  cancer,  if  taken  early,  maj^  be  removed  with  good 
hope  of  a  permanent  cure.  The  extrinsic  cancer  is  a  rapidly  fatal  dis- 
ease, for  which  operation  is  a  desperate  remedy  at  the  best.  Fortunately, 
the  location  of  lar3'ngeal  cancer  brings  the  disease  early  to  the  attention 
of  the  patient  and  drives  him  to  consult  a  physician.  The  sufferer 
perceives  increasing  hoarseness  leading  to  aphonia,  with  pain  as  a  late 
symptom.  The  surgeon,  by  the  aid  of  the  laryngoscope,  discovers  a 
tumor  or  ulceration,  and  should  remove  a  bit  of  it  to  confirm  the  diag- 
nosis of  cancer,  if  possible,  for  that  disease  not  infrequently  has  been 
mistaken  for  benign  papilloma  or  for  tuberculosis.     If  the  case  mns  on 


Fig.  386.— Cohen's  tracheot- 
omy tubes:  1,  Outside  tube  and 
obturator;  2,  obturator;  3,  inside 
tube;  a,  cross-section  of  the  tube 
(Fowler). 


584  THE    FACE    AND    NECK 

without  operation,  death  takes  phice  in  one  of  two  ways — by  suffocation 
or  by  exhaustion  through  metastasis.  The  reader  may  remember  that 
the  latter  event  befell  the  late  Emperor  Frederick,  of  Germany,  whose 
more  urgent  symptoms  were  relieved  by  a  timely  tracheotomy.  Patients 
often  are  loath  to  submit  to  removal  of  the  larynx,  in  which  removal  lies 
the  only  possible  hope  of  cure,  so  that  it  is  not  uncommon  to  see  these 
victims  die  after  a  miserable  existence,  prolonged  by  a  palliative  trach- 
eotomy, which  they  always  welcome  gladh'. 

Various  operdtions  for  the  cure  of  kuyngeal  cancer  are  advocated 
by  various  authorities.  There  is  intralaryngeal  removal;  remo\-al  by 
splitting  the  cartilages  from  without;  Kocher's  subhyoid  pharyngotomy; 
excision  of  one-half  the  larynx,  and  total  extirpation  of  the  larynx,  as 
first  performed  by  Watson  and  Czerny,  and  improved  by  Keen,  Gliick, 
and  others.  I  leave  the  discussion  of  the  first  three  methods  to  other 
pens.  I  am  not  convinced  of  their  efficiency,  for  neither  a  -priori  nor 
by  statistics  do  they  appear  to  be  curative.  Cancer  of  the  larj-nx,  like 
cancer  elsewhere,  calls  for  radical  and  sweeping  excision.  Most  cases, 
therefore,  should  be  treated  by  the  total  extirpation,  a  description  of 
which  may  be  modified  to  cover  partial  extirpation.  Siuichy  methods 
of  total  extirpation  are  described,  but  I  am  convinced  that  ^^^  AV.  Keen's 
method  promises  the  best  satisfaction.  I  must  anticipate  the  descrip- 
tion of  Keen's  method  by  reminding  the  reader  that  the  great  danger 
of  operations  upon  the  larynx  and  trachea  lies  in  the  possibility  of  sub- 
sequent sepsis  and  an  inhalation  pneumonia.  The  mortality  from 
pneumonia  is  high.  The  operation  of  laryngectomy  is  not  very  difficult, 
and  is  not  attended  with  great  shock,  so  that  the  immediate  after-con- 
dition of  the  patient  seems  excellent,  but  the  diffuse  bronchitis  and 
pneumonia,  which  supervene  so  often,  lend  terror  to  an  operation  other- 
wise satisfactory.  All  operators,  therefore,  have  endeavored  to  devise 
some  means  of  cutting  off  the  lower  air-passages  from  the  possibility  of 
a  contamination  extending  downward  from  the  larj-ngeal  wound.  The 
steps  of  Keen's  method  are  somewhat  as  follows:  For  a  week  jirior  to  the 
operation  the  patient's  mouth  and  fauces  should  be  thoroughly  brushed 
and  gargled  frequently,  in  order  to  clear  up  any  possibly  lurking 
source  of  infection.  The  operation  is  performed  with  the  patient's  neck 
extended  over  a  pillow  or  in  Rose's  position,  so  as  to  make  prominent 
the  larynx  and  trachea.  Expose  the  windpipe  from  a])ove  the  hyoid 
bone  to  the  third  tracheal  ring.  Separate  thoroughly,  b}'  blunt  dis- 
section, the  structures  to  be  removed,  and  check  all  bleeding.  Then 
put  the  patient  in  the  Trendelenburg  position,  divide  transversely  the 
trachea  well  below  the  disease,  and  attach  the  lower  tracheal  stump  to 
the  skin,  either  in  the  original  skin  incision  or  in  a  special  skin  button- 
hole, and  intubate  the  trachea,  continuing  the  anesthetic  through  a  nib- 
ber  tube  led  out  of  the  tracheotomy  tube.  The  rest  of  the  operation  may 
be  done  safely  and  at  leisure.  Seize  the  upper  tracheal  stump  and  draw 
it  forward  with  the  attached  larynx.  Carefully  separate  the  parts  from 
the  underlying  esophag-us,  and  if  the  esophagus  be  wounded,  close  it  at 
once  with  stitches.    Remove  entirely  the  diseased  larynx.    Draw  down 


DISEASES   OF  THE    LARYNX  585 

the  epiglottis,  remove  it,  and  complete  the  operation  by  suturing  the 
anterior  wall  of  the  esophagus  to  the  tissues  just  below  the  hyoid  bone, 
so  as  to  prevent  leakage  from  the  mouth  into  the  wound.  Then  remove 
the  tracheotomy  cannula  and  close  the  external  wound,  providing  drain- 
age for  twenty-four  hours.  The  dressings  of  the  laryngeal  wound  and 
of  the  tracheotomy  opening  must  be  kept  separate,  and  Binnie  suggests 
strapping  a  small  frame,  like  a  pillow-box,  over  the  tracheotomy  open- 
ing, so  as  to  protect  it  and  supply  a  base  for  a  gauze  air-filter. 

The  time  of  after-treatment  is  an  anxious  time.  The  patient  should 
be  in  bed  without  a  pillow,  the  foot  of  the  bed  being  slightly  raised,  and 
for  two  days  he  should  be  fed  by  nutrient  enemata.  After  that  he  should 
be  gotten  out  of  bed  daily,  and  should  be  encouraged  to  swallow,  or  to 
take  nourishment  through  a  stomach-tube,  the  nurse  meanwhile  attend- 
ing constantly  and  carefully  to  cleanliness  of  the  wound.  If  all  goes  well, 
the  patient  should  be  beyond  danger  by  the  end  of  the  week. 

Partial  extirpation  of  the  larynx  is  performed  in  much  the  same 
fashion,  one  half  of  the  larynx,  split  from  before  backward,  being  re- 
moved. 

An  encouraging  number  of  cures  have  been  reported  as  a  result  of 
this  operation,  and  the  final  condition  of  the  patients  is  not  so  grievous 
as  one  might  suppose.  In  some  fashion  they  acquire  an  ability  to  talk, 
or  to  whisper  at  least,  and  the  function  of  swallowing  is  completely 
restored. 


CHAPTER  XXII 

THE  NECK 

Most  American  surgeons,  when  they  deal  with  the  surgery  of  the  neck, 
will  think  of  the  brilliant  recent  work  of  Crile  and  of  C.  H.  Mayo.  Crile's 
advocacy  of  extensive  block  dissections,  temporary  occlusion  of  the 
carotids,  and  the  use  of  the  pneumatic  suit  to  combat  shock,  constitutes 
an  important  advance  in  the  surgery  of  this  region;  while  Mayo's  con- 
tributions to  the  treatment  of  goiter — especially  exophthalmic  goiter — 
are  notable.  We  have  already  discussed  many  problems  of  neck  surgery 
— incidentally,  when  we  were  considering  malignant  disease  of  the  mouth 
and  diseases  of  the  upper  air-passages.  Certain  important  groups  of 
glandular  swellings  and  diseases  of  other  cervical  structures  will  occur 
to  surgeons  as  presenting  other  important  problems.  In  this  chapter 
we  shall  consider  deformities  of  the  neck  due  to  cicatrices,  injuries,  and 
neurosis;  tuberculous  adenitis;  cervical  abscess;  tumors  of  the  carotid 
body;  enlargements  of  the  lymph-nodes;  abnormal  cervical  ribs,  and 
thyroid  tumors. 

CICATRICIAL   CONTRACTIONS 

Cicatricial  contractions  due  to  extensive  superficial  burns  of  the 
neck  produce  some  of  the  most  distressing  deformities  with  which  we 
have  to  deal.  The  skin  over  the  front  of  the  neck  is  thin,  delicate,  and 
elastic,  normally  and  necessarily  so  in  order  to  allow  of  free  excursions 
of  the  neck  and  chin.  This  skin,  especially  in  childhood,  is  easily 
destroyed,  when  the  dense  scars  which  supplant  it  contract  often  into 
limiting  bands  which  depress  the  chin,  control  cervical  rotation,  and  hold 
open  the  mouth  in  a  distressing,  disfiguring,  and  humiliating  fashion. 
The  treatment  oi  this  condition  is  by  no  means  easy.  It  does  not  suffice 
to  cut  away  the  bands,  for  new  cicatrices  then  form.  The  surgeon  must 
turn  up  great  flaps,  exposing  considerable  areas  of  raw  surface,  before 
the  normal  movements  of  the  chin  and  neck  can  be  restored;  and  he 
must  then  fill  in  the  raw  surfaces  with  flaps  of  true  skin  taken  from 
the  chest,  shoulders,  or  sides  of  the  neck.  The  chest  skin-flaps  are  best, 
for  skin  from  the  chest  is  elastic  and  allows  of  ready  stretching  into 
place,  while  the  consequent  gap  left  on  the  chest  can  usually  be  filled  in 
by  drawing  over  it  adjacent  skin  or  by  applying  Thiersch  grafts. 

TORTICOLLIS 

Torticollis,  or  wry-neck,  is  another  distressing  affection  of  the  neck, 
but  not  so  grievous  generall}-  as  the  cicatricial  deformity.  There  are 
sundry  forms  and  causes  of  torticollis :  cicatrices  may  cause  it^  of  a  nature 

586 


TORTICOLLIS  587 

similar  to  those  already  described;  articular  torticollis  is  due  to  an 
inflaniniation  of  the  vertebral  joints,  and  falls  to  the  care  of  the  ortho- 
pecUc  surgeon  for  treatment  by  apparatus;  muscular  torticollis  is  seen 
in  new-born  infants,  born  by  the  breech,  and  is  the  result  of  partial  rup- 
ture of  the  sternomastoid  fibers.  A  hematoma,  suggesting  a  tumor 
mass,  appears  shortl}',  but  the  disablement  is  readily  curable  by  simple 
surgical  measures — bandaging  and  the  wearing  of  a  supporting  collar. 
Spasmodic  torticollis  interests  us  especially,  though  little  advance 
in  its  treatment  has  been  suggested  since  the  publication  of  Walton's 
admirable  paper  in  1898.^ 


Ml 

Fig.  387. — Cicatrix  from  burn.     Personal  case  (Massachusetts  General  Hospital). 

As  Walton  says,  "  spasmodic  torticollis  is  a  disorder  of  the  cortical 
centers  for  rotation  of  the  head."  The  pathogeny  of  the  disorder  is 
not  altogether  apparent,  but  symptoms  of  neurasthenia,  and  more  rarely 
of  hysteria  or  mental  disease,  may  be  associated  with  the  ailment.  The 
victims  are  commonly  between  thirty  and  fifty  years  of  age,  though 
young  persons  are  not  exempt.  The  patient  may  appear  normal  upon 
one's  first  inspection,  but  some  slight  irritation,  not  always  obvious, 
brings  on  a  spasm  of  muscles,  throwing  the  head  to  one  side  in  a  painful, 
distressing,  and  somewhat  ludicrous  fashion.  The  muscles  generally 
affected  are  the  sternomastoid  and  trapezius,  more  rarely  the  splenius 
capitis,  the  complexus,  the  trachelomastoid,  and  the  inferior  oblique. 
1  G.  L.  Walton,  Amer.  Jour.  Med.  Sci.,  March,  1898. 


588 


THE   FACE   AND    NECK 


In  most  cases  the  spasm  attacks  the  sternomastoid  of  one  side  and  the 
posterior  rotators  of  the  other,  so  that  these  two  grou])s  of  muscles 
combine  to  rotate  the  oc('ij)ut  and  give  the  chin  an  u])\vard  tih.  Karely 
both  sternomastoids  alone  are  affected,  or,  still  more  rarely,  the  pos- 
terior rotators  of  both  sides. 

You  can  do  little  for  these  cases  Avith  drugs,  electricity,  massage, 
and  similar  remedies,  though  occasionally  a  confining  collar  will  give 
the  patient  the  desired  comfort.  Nor  are  operations  altogether  satis- 
factory, and  such  operations  as  we  can  do  vary  greatly  in  their  severity 
from  simple  nerve-stretching  to  extensive  tenotomies.     If  an  opera- 


Fig.  388. — Spasmodic  torticollis  (Massachusetts  General  Hospital). 

tion  be  undertaken,  therefore,  it  is  good  practice  to  resect  first  the 
spinal  accessory  nerve  on  the  affected  side,  in  the  hope  that  this  will 
relieve  the  symptoms.  Should  this  operation  fail,  the  surgeon  may  pro- 
ceed to  the  more  radical  division  and  avulsion  of  the  posterior  branches 
of  the  three  first  spinal  nerves  on  the  opposite  side  (Keen) ;  or  even  to 
tenotomies  of  all  the  muscles  affected  (Kocher).  After  the  operation 
the  patient's  head  should  be  supported  for  at  least  three  weeks  in  a  well- 
fitting  Thomas  collar,  and  the  surgeon  must  attend  specially  to  the 
patient's  general  condition,  directing  careful  massage,  suitable  tonics, 
an  out-of-doors  rest-cure,  or  a  long  vacation.     Persistence  in  these 


CERVICAL  ADENITIS 


589 


measures  will  often  relieve  completely  the  sufferer;  and  the  destruction 
of  nerves  and  muscles,  even,  may  be  so  far  recovered  from  as  to  leave 
the  patient  with  a  useful  and  sightly  neck. 

CERVICAL  ADENITIS 

Cervical  adenitis  furnishes  frequent  occasions  for  operations  u])on 
the  neck.     The  lymphatics  of    the   neck   drain   a    region    peculiarly 


Fig.  389. — The  lymph-nodes  of  the  neck  (Campbell). 

susceptible  to  infection,  and  for  this  reason  the  nodes  of  the  neck,  more 
than  any  other  group  of  nodes  in  the  body,  are  wont  to  be  found  enlarged. 
Anatomists  divide  the  cervical  lymphatic  nodes  into  two  sets,  the  super- 


590  THE    FACE    AND    NECK 

ficial  and  the  deep — those  immediately  below  the  platysma,  and  those 
resting  upon  the  carotid  sheath.  For  the  clinician,  however,  no  such 
invariable  division  is  possible;  the  lymphatic  channels  communicate 
freely  with  each  other,  and  infections  of  nodes,  both  superficial  and 
deep,  frequently  coexist.  Observe  the  interesting  fact,  recently  pointed 
out  by  Crilc:  the  lowest  cervical  nodes  in  the  region  of  the  clavicle  .seem 
to  act  as  a  collar  or  barrier,  below  which  malignant  processes  extend 
slowly  and  late — malignant  as  compared  with  inflammatory  involve- 
ments. The  latter  extend  early  below  the  clavicle.  For  the  surgeon, 
then,  dealing  with  cervical  adenitis,  the  important  nodes  are  those 
immediately  behind  the  posterior  belly  of  the  digastric  muscle,  the 
nodes  Ij'ing  upon  the  carotid  sheath,  and  those  in  the  posterior  cervical 
triangle.  (See  Chapter  XX.)  Be  it  noted,  however,  that  the  super- 
ficial cervical  nodes  communicate  freely  with  the  axillary  nodes,  while 
the  deep  cervical  nodes  are  associated  with  the  nodes  of  the  mediasti- 
num. When  discussing  malignant  disease  of  the  mouth,  I  pointed  out 
that  the  buccal  cavity,  the  tongue,  and  the  lips  drain  into  the  cervical 
lymph-nodes.  For  this  reason  infections  in  the  mouth  set  up  inflam- 
mations in,  and  result  in  abscesses  of,  the  neck;  but  the  most  impor- 
tant source  of  infection,  as  concerns  the  cervical  nodes,  is  the  tonsils. 
Especially  does  this  appear  to  be  true  of  tuberculous  invasions,  so  that 
the  surgeon,  w^hen  confronted  with  a  case  of  tuberculous  cervical  adeni- 
tis, should  examine  invariably  the  tonsils,  and  whatever  be  his  treatment 
of  the  swollen  neck,  he  should  correct  the  lesion  in  the  throat. 

Children  most  commonly  are  sufferers  from  lymphatic  infections  of 
the  neck, — infections  especially  of  the  tuberculous  type, — but  these 
diseases  attack  persons  of  all  ages  and  of  both  sexes.  In  the  old  days 
these  tuberculous  patients  w^ere  called  ''  scrofulous,"  and  the  ailment 
was  dubbed  "  scrofula."  Such  patients  may  present  that  typical, 
hectic,  anemic  appearance  which  we  associate  with  victims  of  tubercu- 
losis; but  the  typical  appearance  is  by  no  means  the  rule.  We  find 
tuberculous  nodes  in  the  necks  of  robust-looking  men.  Most  of  the 
patients,  however,  appear  ill.  They  are  anemic ;  their  appetites  are  poor, 
and  they  are  often  emaciated.  Frequently  the}-  have  fever,  with  a 
temperature  ranging  between  99°  and  101°  F.  Such  patients  will 
tell  you  that  they  have  been  running  clown  for  a  long  time,  and  that,  as  a 
result  of  being  rim  down,  lumps  have  appeared  in  their  necks.  On  ex- 
amination the  surgeon  may  find  enlarged  nodes  in  the  axillse  and  groins 
also,  but  in  the  neck  especially,  on  one  or  both  sides,  he  will  find  swellings, 
large  or  small,  multiple  or  single,  hard  or  fluctuant,  sometimes  resemb- 
ling a  chain  of  marbles  lying  on  the  front  of  the  sternomastoid,  some- 
times presenting  a  single  ovoid  tumor  under  the  angle  of  the  jaw  and 
as  large  as  a  man's  fist.  Frequently  there  is  a  history  of  recurring  at- 
tacks of  "  swollen  glands,"  enlarging  and  subsiding,  with  corresponding 
fluctuations  in  the  patient's  general  health.  Sometimes  one  finds  pul- 
monary disease  or  evidence  of  tuberculosis  within  the  abdomen  or  joints, 
but  we  are  not  dealing  here  with  such  complications  of  cervical  adenitis. 

The  treatment  of  tuberculous  cervical  adenitis  is  not  at  all  a  simple 


CERVICAL   ADENITIS  591 

matter,  and  the  treatment  has  varied  greatly  in  the  past  fifteen  years. 
At  times  it  has  been  the  custom  to  poultice  the  swelling  and  to  open 
and  drain  it  after  it  has  ripened  into  an  abscess.  That  is  bad  treat- 
ment. We  recognize  now  the  importance  of  eliminating  those  tubercu- 
lous masses  as  early  as  possible,  lest  they  serve  as  foci  for  the  spread  of 
a  general  tuberculosis.  But  elimination  of  lymphatic  tuberculosis 
does  not  always  and  necessarily  imply  incision.  Yer}-  many  of  these 
persons  will  recover  sound  health  under  a  careful  regime  and  a  per- 
sistent out-of-doors  hfe.  Unfortunately,  numbers  of  the  poor  patients 
seen  in  large  hospital  clinics  cannot  secure  the  proper  out-of-doors  treat- 
ment, so  that  surgeons  often  become  weary  and  skeptical  in  advising 
such  a  course.  That  skeptical  attitude  of  the  surgical  mind  is  irrational. 
No  theory  of  therapeutics  is  more  certain  and  well  established  than 
that  a  great  majority  of  cases  of  tuberculous  adenitis  will  recover  if 
they  can  pursue  faithfully  and  uninteriTiptedly  for  six,  eight,  or  twelve 
months  a  proper  life  in  the  open  air.  One  must  supplement  this  course  by 
an  abundance  of  good  food  and  such  tonics  as  iron,  malt,  and  the  various 
forms  of  fats.  There  will  remain,  however,  a  considerable  proportion 
of  patients  who  either  cannot  secure  the  out-of-doors  treatment  or  fail 
to  recover  under  that  treatment.  For  some  of  these  persons  therapeutic 
injections  of  Koch's  new  tubercuhn  may  be  appropriate,  injections  ad- 
ministered under,  and  controlled  by,  the  opsonic  therapy  of  A.  E.  Wright. 
There  remain  finally  the  large  number  of  cases  which  must  look  for  relief 
or  cure  through  a  surgical  operation. 

Operative  treatment  of  tuberculous  adenitis  concerns  itself  naturally 
with  two  classes  of  cases,  according  to  the  nature  or  extent  of  the  in- 
flammatory process:  (1)  There  are  the  hard  and  nodular  masses.  It  is 
a  simple  matter  to  cut  down  upon,  isolate,  and  excise  these  masses,  which 
have  not  suppurated  or  become  caseous.  (2)  There  are  the  abscesses. 
It  is  impossible  to  excise  thoroughly  tuberculous  disease  which  has 
advanced  beyond  the  node  capsule,  has  invaded  neighboring  structures, 
and  involved  generally  the  soft  parts  of  the  neck  in  a  degenerative 
process. 

Briefly,  the  nodes  which  are  still  intact  should  be  removed  totally, 
so  far  as  may  be.  Small  masses  of  nodes  in  the  upper  part  of  the  cervical 
region  may  be  reached  by  Bollinger's  method,  which  consists  in  making 
a  curved  incision  along  the  line  of  the  hair,  starting  from  just  behind  the 
ear.  The  advantage  of  this  method  is  that  it  leaves  no  perceptible  scar; 
but  it  is  not  a  satisfactory  method  by  which  to  reach  thoroughly  aU 
parts  of  the  neck.  It  is  a  burrowing  and  somewhat  blind  performance, 
but  I  admit  that  I  have  found  it  useful  in  a  few  selected  cases.  Other 
groups  of  nodes,  relatively  small,  may  well  be  reached  through  a  trans- 
verse incision  at  any  level  of  the  neck,  and  I  recommend  this  incision  in 
suitable  cases,  for  it  follows  the  natural  line  of  cleavage  of  the  skin, 
and  there  results  an  insignificant  scar.  There  will  remain  always  those 
more  extensive  and  involved  cases  presenting  masses  of  nodes  filling 
the  whole  neck  from  the  jugular  fossa  down  to  and  below  the  clavicle, 
and  extending  widely  into  the  posterior  cervical  triangles.     To  remove 


592 


THE    FACE    AND   NECK 


these  nodes  necessitates  an  operation  often  as  far  roaehino;  and  crippling 
as  the  extensive  block  dissection  of  the  neck  for  cancer — indeed,  the 
description  of  these  block  dissections  in  Chapter  XX  of  this  book  may 
be  made  to  apply  to  extensive  dissections  of  tuberculous  disease,  but  with 
this  difference,  that  tuberculous  disease  of  the  neck  does  not  often  in- 
volve other  than  lyni]:)hatic  structures,  so  that  the  surgeon  is  not 
forced  to  remove  muscles,  vessels,  and  nerves  even.  Rarely,  I  have 
been  obliged  to  excise  a  tuberculous  sternomastoid  muscle,  but,  as  a  rule, 
one  can  find  abundant  room  for  the  dissection  by  cutting  through  and 
turning  back  out  of  the  field  the  sternomastoid,  to  be  restored  carefully 
with  stitches  at  the  close  of  the  operation.  It  is  well,  in  dissecting  out 
great  masses  of  nodes,  and  after  having  turned  back  the  skin-flaps  and 
sternomastoid,  to  begin  at  the  clavicle  and  work  upward,  making  a  clean 


Fig.  390. — Scarless  method  for  removing  enlarged  cervical  nodes  (Bollinger). 

sweep  of  all  the  involved  nodes  to  the  last  one,  which  is  usually  found 
almost  as  high  up  as  the  jugular  fossa.  Writers  divide  somewhat  fanci- 
fully the  groups  to  be  removed/  discussing  special  maneuvers  for  special 
groups.  It  is  true  that  enlarged  nodes  tend  to  follow  well-defined  planes 
of  least  resistance,  that  certain  groups  tend  to  remain  limited  to  the 
digastric  region  and  others  to  the  carotid  region,  but  it  is  imjDossible  to 
assign  all  cases  to  definite  classes.  In  general  terms,  however,  the 
surgeon  should  attempt  to  follow  Sutcliffe's  three  rules:  (1)  The  operation 
should  be  as  complete  as  possible;  (2)  the  spinal  accessory  and  other 
important  nerves  with  the  vessels  should  escape  injury;  (3)  the  incision 
should  be  planned  so  as  to  make  the  resulting  scar  as  little  visible  as 
possible. 

1  W.  G.  Sutcliffe,  Brit.  Med.  Jour.,  May  13,  1905. 


WOUNDS   OF  THE    THORACIC   DUCT 


593 


Our  discussion  of  the  opcnitivc  treatment  of  cervical  adenitis  hith- 
erto has  dealt  with  the  removal  of  encapsulated  masses.  It  remains  to 
say  a  word  regarding  tlie  broken-down,  suppurating  nodes  involved  in 
mixed  infections.  These  inflamed  nodes  and  the  resulting  abscesses  are 
those  which  "  point"  beneath  the  skin,  break  through,  and  discharge 
externally,  and  in  their  healing  leave  those  ugly  scars  of  the  neck  with 
which  we  are  all  familiar.  If  a  limited  abscess  has  formed  without  ex- 
tension to  other  nodes,  it  may  be  tapped,  washed  out,  and  drained 
through  a  fine  cannula,^  which  should  remain  in  place  for  about  a  week, 
when  it  may  be  removed,  and  the  little  sinus  allowed  to  heal.  An  im- 
perceptible scar  usually  results.  Extensive,  suppurating,  burrowing 
tuberculous  disease,  on  the  other  hand,  must  be  opened  thoroughly, 


Fig.  391. — Small  transverse  incisions. 

cureted,  the  deep  parts  painted  with  iodin,  and  the  wound  packed  and 
drained,  with  a  resulting  ugly  scar. 

Such,  in  general,  are  the  methods  of  treatment  applicable  to  tuber- 
culous cervical  adenitis.  The  surgeon  should  remember  always  that 
after  an  apparent  cure  these  patients  are  still  subject  to  reinfection,  and 
should  be  taught  carefully  the  importance  of  leading  properly  regulated 
lives,  under  the  best  obtainable  surroundings. 


WOUNDS  OF  THE  THORACIC  DUCT 

Wounds  of  the  thoracic  duct  are  reported  from  time  to  time,  and 
every  surgeon  who  has  occasion  to  dissect  extensively  the  deep  tissues 

^  Briggs'  cannula. 
38 


594  THE    FACE    AND    NECK 

of  the  neck  probably  has  been  guilty  of  damaging  this  important  struc- 
ture. I  have  myself  wounded  the  duct  twice.  Some  years  ago  Allen 
and  Briggs  collected  17  cases  from  the  reports  of  various  operators.' 
Fortunately,  the  lesion  heals  in  most  cases  without  great  trouble  or 
special  care.  The  wound  in  the  duct  cannot  often  be  repaired,  though 
sometimes  it  may  be  found  and  sutured.  Allen's  fourth  conclusion  is 
important — "  until  repair  of  the  duct  is  thought  to  be  complete,  nutrition 
should  be  sustained  on  albuminous  material,  with  possibly  a  small 
amount  of  carbohydrates,  but  with  an  absolute  exclusion  of  fats." 

DEEP  CERVICAL   ABSCESS 

Deep  cervical  abscess  is  a  serious  condition,  which  may  simulate  or 
be  confused  with  suppurating  lymph-nodes,  but  the  deep  abscess  to  which 
I  refer  owes  its  origin  to  an  inflammation  of  other  structures,  such  as 
the  parotid  gland,  the  submaxillary  gland,  or  the  cervical  vertebrae. 
These  deep  abscesses  burrow  far,  and,  following  the  fascia  down  the 
planes  of  the  neck,  may  reach  the  chest  and  cause  the  most  serious  kind 
of  trouble.  Such  abscesses,  therefore,  may  be  regarded  generally  as 
"  cold  abscesses."-  They  are  painful;  they  are  extremely  tense;  they 
are  associated  with  a  moderate  rise  of  temperature;  they  cause  pro- 
found prostration,  and  thej^  must  be  treated  by  incision  and  drainage 
as  soon  as  they  are  discovered.  Some  of  them,  located  high  in  the 
neck  and  observed  early  in  their  course,  may  be  cured  after  tapping  by 
the  injection  of  iodoform  glycerin  (3  drams  of  iodoforai  to  3  ounces  of 
glycerin),  but  this  maneuver  has  its  dangers.  It  may  not  check  the 
disease,  in  which  case  the  abscess  must  be  opened  freely  and  drained  as 
though  de  novo. 

PEDICULI  CAPITIS 

Pediculi  capitis  (head  lice)  often  cause  infections  of  the  supei-ficial 
lymph-nodes  posterior  to  the  sternomastoid  muscles.  A  soft  abscess 
in  the  region  of  the  mastoid  process,  especially  in  an  ill-kempt  child, 
always  should  prompt  the  surgeon  to  examine  the  patient's  head. 
Often  he  will  find  in  the  hair  lice  associated  with  a  diffuse  dermatitis. 
The  treatment  consists  not  only  in  opening  the  abscess,  but  in  making 
the  proper  applications  of  crude  petroleum  to  the  head  in  order  to  destroy 
the  parasites. 

LYMPHATIC  CYSTS 

Lymphatic  cysts  (one  form  of  "  hydrocele  of  the  neck")  are  some- 
what uncommon  congenital  cysts,  which  appear  on  one  or  both  sides  of 
the  neck,  usually  anterior  to  the  sternomastoid  muscles.  Rarely  they 
may  extend  into  the  axilla  or  chest.  They  may  be  monolocular  or  multi- 
locular.  They  originate  beneath  the  deep  fascia,  but  ))ortions  of  them 
may  become  subcutaneous.     They  are  thin  walled  and  contain  a  translu- 

^  Dudley  P.  Allen  and  C".  F].  Briggs,  Amer.  Med.,  September  14,  1901. 

2  "  Cold  abseess,"  usually  a  chronic  abscess  forming  slowly  witliout  marked 
inflammatory  sjonptoms;  or  sometimes  a  collection  of  pus  remote  from  its  .source 
of  origin,  e.  g.,  psoas  abscess  in  the  groin,  the  result  of  inflammation  of  vertebrte. 


THK    CAROTID    GLAND 


595 


cent  serous  fluid,  which  often  gives  them  the  appearance,  when  inspected 
through  the  hych'oscope,  of  scrotal  hydrocele.  Hydrocele  of  the  neck 
appears  in  children;  rarely  it  persists  after  the  fifteenth  year.  It  dis- 
appears spontaneously  as  a  result  of  inflammatory  or  atrophic  changes. 
These  cysts  may  be  aspirated  and  the  sac  injected  with  a  5  per  cent, 
solution  of  carbolic  acid — at  once  removed;  or  they  may  be  left  for  a 
spontaneous  cure. 

THE   CAROTID   GLAND i 

There  lies  in  the  fork  of  the  carotid  artery,  where  it  divides  into 
its  external  and  internal  branches,  a  minute  structure,  varying  nor- 
mally in  size  from  4  to  7  cm.  in 
length,  which  recently  has  become 
the  subject  of  active  surgical  in- 
terest, for  it  ma}'  take  on  malignant 
changes,  may  enlarge  so  as  to  disfig- 
ure the  neck,  and  may  cause  distress- 
ing symptoms,  ^^on  Haller,  in  the 
middle  of  the  eighteenth  century, 
described  the  carotid  gland,  but  not 
until  1S91  was  it  recognized  as  a 
possible  seat  of  tumors.-  In  1906 
Keen  had  coUected  27  cases,  and 
numerous  other  cases  have  been  re- 
ported. 

Tumors  of  the  carotid  gland  ap- 
pear in  persons  of  all  ages,  though 
the}'  are  most  common  in  early 
adult  Hfe,  and  are  divided  equally 
between  males  and  females.  The 
ordinary  tumor  of  the  carotid  gland 
grows  slowly  and  appears  first  as  a 
smaU  lump,  a  little  larger  than  an 
alrhond.  It  reaches  a  considerable 
size  and  is  ovoid  and  firm,  with  a 
well-defined  capsule  closely  adherent 
to  the  vessels;  while  its  substance, 
divided  by  numerous  septa,  is  brown 
or  broT\Tiish-red   on  section.     It  is 

fed  constantly  by  a  small  arteiy  from  the  internal  carotid.  TMiile 
there  is  still  a  variety  of  opinion  regarding  the  structure  of  the  gland, 
it  appears  that  the  essential  elements  are  blood-vessels  and  cells;  and 
among  the  cells  and  in  the  stroma  there  are  elements  to  which  have 
been  applied  the  terms  "  chromophile"  and  ''  chromofiffine,"  to  which 

1  W.  W.  Keen  and  John  Funke,  Tumors  of  the  Carotid  Gland,  Trans.  Amer.  Med. 
Assoc,  section  of  Surgeiy  and  Anatomy,  1906.  This  is  the  most  comprehensive 
.and  satisfactory  article  as  yet  published  on  this  interesting  subject. 

-  IMarchand,  Virchow's  Festschrift,  1891,  vol.  i. 


Fig.  392. — Carotid  gland,  showing 
the  three  carotids  and  their  relation  to 
the  tumor  (Scudder). 


596  THE    FACE    AND    NECK 

are  attributed  an  im])ortant  functional  significance  similar  to  that  as- 
cribed to  elements  in  the  suprarenal  glands.  "  Mulon  concludes  that 
the  chromafiffine  cells  secrete  a  substance  which,  when  introduced  into 
animals,  acts  like  adrenalin  in  raising  the  arterial  i)rcssure."^  The 
tumor  is  always  intimately  associated  with  the  carotid  vessels,  and  cannot 
be  separated  from  them  with  safety.  By  its  pressure  it  may  encroach 
upon,  or  ol:)literate  even,  the  artery's  lumen. 

A  patient  with  one  of  these  growths  suffers  little  discomfort  until 
the  tumor  has  reached  a  considerable  size.  Rarely  is  there  pain,  dysp- 
nea, or  involvement  of  the  sympathetic  and  pneumogastric  nerves 
sufficient  to  cause  changes  in  the  pupil  or  in  the  heart-rate.  The  tumor 
may  grow  slowly  for  many  }'eai's  and  then  increase  ra])idly  in  size,  so 
that  the  patient  seeks  relief  for  the  deformity  rather  than  for  any  actual 
discomfort.  When  the  surgeon  comes  to  examine  one  of  these  growths, 
he  may  mistake  it  readily  for  an  enlarged  Ij-mph-node.  The  tumor 
lies  under  the  sternomastoid  muscle  and  presents  a  long,  ovoid  swelling 
in  the  line  of  the  muscle,  a  swelling  movable  laterally,  but  not  up  and 
down.  The  skin  is  not  discolored  or  adherent,  and  a  transmitted  pul- 
sation, without  thrill  or  expansile  impulse,  can  be  felt.  In  their  early 
stages  these  tumors  are  not  malignant,  though  prompt  removal  may  be 
followed  by  apparent  recurrence,  probably,  as  Keen  says,  from  micro- 
scopic rests  W'hich  were  overlooked.  Later,  with  the  development  of 
the  tumor,  the  histologic  elements  undergo  marked  and  peculiar  modi- 
fications, resembling  somewhat  those  changes  seen  in  the  so-called  hyper- 
nephroma. For  the  sake  of  a  word,  and  in  order  to  define  the  clinical 
status  of  the  larger  tumors  of  the  carotid  gland,  it  would  not  be  im- 
proper to  group  them  with  the  endothcliomata  (Fur>ke). 

With  this  understanding  of  the  clinical  characteristics,  the  progress, 
and  the  nature  of  carotid  gland  tumors,  the  surgeon  ma}-  be  able  to  make 
a  correct  diagnosis,  and  should  proceed  guardedly  to  advise — 

Treatment. — It  is  an  interesting  fact  that  the  removal  of  these 
tumors  is  not  the  easy,  safe,  and  curative  process  one  would  expect. 
The  death-rate  from  operation  is  about  25  per  cent.,  so  that  it  is  best 
to  operate  only  in  the  face  of  serious  functional  troubles  or  the  rapid 
evolution  of  an  apparently  malignant  growth.  In  operating,  and 
after  exposing  fully  the  growth,  the  surgeon  should  isolate  it  carefully 
from  all  neighboring  nerves  and  other  adjacent  stnictures  with  the  ex- 
ception of  the  carotid  vessels.  He  cannot  safelj'  separate  it  from  these 
vessels.  Then  he  must  ligate  the  carotid  artery  and  its  two  main 
divisions  above  and  below  the  tumor,  divide  the  arterial  trunks,  and 
remove  the  growth  with  the  included  vessels.  If  the  ])atient  surviA-e 
the  immediate  .shock  of  the  operation,  recovery  should  be  prompt  and 
uneventful,  and  the  convalescence  be  completed  within  ten  days.  I 
have  elaborated  this  subject  of  the  carotid  gland  perhaps  unduly  on 
account  of  the  novelty  and  recent  interest  in  the  matter. 

Another  subject  for  surgery  in  the  neck,  a  condition  shown  bj^  skia- 
graphs to  be  relatively  common,  is  the  cervical  rib. 
1  Keen  and  Funke,  ibid.,  p.  60. 


DISEASE    OF   THE    THYROID    GLAND  597 


CERVICAL   RIB 


This  abnormality  is  not  a  true  rib,  but  is  a  peculiar  lengthening 
of  the  transverse  process  of  the  seventh  cervical  vertebra  on  one  or 
both  sides.  No  symptoms  or  special  discomfort  commonly  are  caused 
by  a  cervical  rib,  so  that  the  patient  may  go  through  life  without  knowl- 
edge of  this  peculiarity  in  his  anatomy.  Occasionally,  however,  tor- 
sion of  the  subclavian  artery  may  be  caused  by  the  rib,  resulting,  per- 
haps, according  to  G.  Fisher,  in  subclavian  aneurysm.  The  more  com- 
mon changes,  however,  are  trophic,  with  an  ischemia  and  consequent 
necrosis  of  some  of  the  parts  supplied  by  the  artery  affected.  W.  W. 
Babcock  "■  reports  an  interesting  case  of  this  sort  in  which  the  right 
hand  was  cold,  pulseless,  and  numb,  at  times,  and  affected  by  ulcers, 
with  gangrene  of  three  fingers.  Excision  of  a  cervical  rib  on  the  cor- 
responding side  cured  the  disorder. 

We  come  now  to  a  discussion  of  the  most  hotly  debated,  difficult, 
interesting,  and  promising  subject  in  the  whole  field  of  surgery  of  the 
neck,  namely,  affections  of  the  thyroid  gland. 

DISEASE  OF  THE  THYROID  GLAND 

Goiter  is  the  common  and  important  disease  of  the  thyroid  gland, 
and  I  suppose  goiter  shares  with  cancer  and  ''  stone"  the  honors  of 
literature — history  and  fiction.  Goiter  has  always  been  regarded  as  a 
disease  peculiar  to  mountain  folk,  and  the  Swiss  especially  are  notable 
as  victims  of  this  growth.  It  is  not  surprising,  therefore,  that  we  find 
in  Theodor  Kocher,  of  Bern,  the  most  eminent  exponent  of  this  in- 
teresting theme. 

You  will  see  in  all  the  old  surgeries  the  striking  pictures  of  goiter, 
enormous  tumors  of  the  thyroid  gland,  as  large  as  a  man's  head  or  larger. 
These  are  the  classic  pictures.  Nowadays,  thanks  to  the  activities  of 
surgeons,  such  great  goiters  rarely  are  seen,  for  we  have  learned  how  to 
combat  the  disease,  have  ascertained  that  many  forms  of  goiter  are  amen- 
able to  medical  treatment,  and  that  the  rest  generally  may  be  removed 
with  safety.  Two  facts  regarding  goiter,  interesting  to  surgeons  es- 
pecially, have  been  demonstrated  in  recent  years:  (1)  That  lying  behind 
the  lobes  of  the  thyroid  one  finds  four  or  more  minute  bodies,  the  size  of 
small  peas,  and  known  as  parathyroid  glandules,  the  presence  or  absence 
of  which  has  an  extremely  important  bearing  on  function  and  on  life; 
and  (2)  that  that  curious  disease,  exophthalmic  goiter,  first  described 
by  Graves  in  1835,  often  may  be  cured  by  a  surgical  operation.  These 
and  kindred  matters  we  shall  discuss  shortly. 

Let  us  now  consider  systematically,  but  briefly,  some  of  the  details 
and  conditions  of  the  natural  history  and  treatment  of  disease  of  the 
thyroid  gland. 

The  gland — a  ductless  gland — is  a  horseshoe-shaped  organ,  lying 
across  the  trachea  immediately  below  the  cricoid  cartilage;  one  lobe  of 
1  Amer.  Med.,  October  7,  1905. 


598 


thp:  face  and  neck 


Qo^^l-/ 


the  gland  on  cither  side  of  the  trachea,  the  lobes  connected  by  an  isth- 
mus. This  is  the  normal,  commonly  accepted  descrij^tion,  but  the  gland 
varies  greatly  in  appearance.  Often  it  is  dumV^-bell  shaped.  Often 
there  springs  from  the  isthnuis  and  runs  upward  in  the  middle  line  of 
the  neck  toward  the  hyoid  bone  a  third  lobe,  or  })}-ramidal  process. 
Albert  Kocher  states  that  this  pyramidal  process,  round  and  worm-like, 
is  found  in  most  thyroid  glands,  that  it  varies  greatly  in  length,  and  rarelv 
extends  to  the  hyoid.  The  thyroid  gland  develops  out  of  the  ventral 
wall  of  the  phar3'nx  from  a  median  proliferation.  Observe  then  this 
important  fact — this  pi-oliferation,  or  ductus,  may  fail  to  become  ob- 
literated, wdth  the  result  that  wandering  or  accessory  thyroids  are  formed, 
usually  trifling  affairs,  quite  isolated  from  the  main  gland.     One  finds 

them  above  or  below^  the  hyoid,  or 
in  front  of,  or  behind,  the  trachea. 
The  wandering  th\'roids  are  to  be 
distinguished  carefully  from  the 
parathyroids. 

Parathyroids. — Wandering  thy- 
roids may  develop  tumors  and 
goiters  in  unexpected  positions. 
Parathyroids  are  stinictures  of  quite 
different  origin  and  function  from 
wandering  thyroids.  Parathyroids 
develop  from  the  third  and  fourth 
bronchial  pouch,  and  are  constantly 
present  in  man.  Generally,  there 
are  four  parathyroids, — two  upper 
and  two  lower, — so  that  they  are,  as 
it  were,  placed  in  pairs  on  either  side 
of  the  trachea,  embedded  in  loose 
connective  tissue  behind  the  thyroid 
gland  itself.  The  tissue  in  which 
they  lie  is  derived  from  the  deep 
cervical  fascia,  and  is  known  as  the 
external  thyroid  capsule.  Occa- 
sionally there  exist  wandering  groups  of  parathyroid  cells  or  glandules 
even,  sometimes  outside  of  the  th3'roid  gland  and  sometimes  within  it. 
The  thyroid  gland  itself  lies  beneath  the  suix'rficial  muscles  of  the 
neck, — the  platysma,  stemomastoids,  sternothyroids,  etc., — and  is 
regarded  as  having  two  capsules — the  loose  external  capsule  of  which 
I  have  spoken  (which  contains  the  recurrent  laryngeal  nerve)  and  the 
firm  iimer  capsule  proper,  which  strips  with  difficulty  and  sends  pro- 
longations between  the  lobes  of  the  gland.  As  to  the  blood-  and  nerve- 
supply  of  the  thyroid  gland,  suffice  it  to  say  that  there  are  the  two 
superior  thyroid  arteries  and  the  two  inferior  thyroid  arteries,  with 
occasionally  the  thyroidea  ima.  The  veins  of  the  gland  spring  especially 
from  the  region  of  the  isthmus,  are  exceptionally  large  and  numerous, 
and  the  gland  is  extremely  vascular.     The  nerves  are  derived  from  the 


Fig.  393.— The  thyroid  gland:  A,  A, 
The  lobes;  B,  the  isthmus;  C,  the  in- 
constant middle  lobe  (Campbell). 


DISEASE    OF   THE    THYROID    GLAND  599 

superior  ganglion  of  the  sym])athetic  and  from  the  lar5Tigeal  branches 
of  the  pneuniogastric,  and  they  accompany  the  blood-vessels.  The 
thyroid  is  a  ductless  gland,  normally  reddish  or  yellowish  red  in  color, 
the  cut  surface  finely  granular  and  exuding  in  considerable  amount  a  col- 
loidal material — a  clear,  yellowish,  slightly  sticky  fluid.  The  gland  sub- 
stance is  made  up  of  closed  tubules,  each  containing  the  colloid  material, 
completely  filling  the  tubules  or  follicles.  The  wandering  thyroids  have 
a  structure  like  th^t  of  the  thyroid,  but  the  parathyroids  have  a  structure 
quite  different — a  thin,  connective-tissue  capsule  sending  out  fibers  into 
the  substance  of  the  little  gland,  with  a  stroma  containing  blood-vessels 
and  lymph- vessels,  and  a  protoplasm,  either  granular  or  clear. 

A  few  words  about  the  functions  of  the  thyroids  and  parathyroids. 
As  Albert  Kocher  states,  "  the  high  iodin-content  of  the  thyroid  gland  is 
its  most  characteristic  feature,  and  the  iodin-containing  albumin  of  the 
gland  (iodothyrin)  is  capable  of  replacing  the  thyroid  secretion.  The 
amount  of  iodin  in  the  gland  usually  is  proportional  to  the  kind  and 
quantity  of  colloid  material  present.  The  secretion  of  the  thyroid 
gland  in  some  fashion  enters  the  circulation,  and  we  know  that  it  exer- 
cises a  metabolic  function  in  the  bod5^  Through  some  unknown  chemical 
process  the  gland  has  a  special  influence  on  the  nervous  system  and  vas- 
cular system;  the  skin  and  epithelial  structures;  the  bones  and  sexual 
organs." 

The  parathyroid  glandules  have  a  function  which  is  not  so  apparent, 
but  the  thyroid  and  parathyroids  certainly  act  in  conjunction  and  are 
not  independent  of  each  other.  We  may  assert  tiiily  one  important 
and  negative  function  of  the  parathyroids.  When  present,  they  are 
antitoxic.  Remove  the  parathyroids  and  the  patient  will  fall  a  victim 
to  tetany. .  At  least  two  parathyroids  are  necessary  to  sustain  properly 
the  function  of  these  interesting  organs. 

Before  taking  up  a  discussion  of  the  ordinary  enlargements  of  the 
thyroid  it  will  be  instructive  to  consider  briefly  those  diseases  which 
may  arise  from  interference  with  the  functions  of  the  thyroid  and  para- 
thyroids. These  so-called  functional  diseases  are  dependent  upon 
suppression  of  the  secretion  or  upon  hypersecretion  of  the  glands. 
Loss  of  the  thyroid  function  produces  sundry  striking  disturbances: 
the  myxedema  of  cretinism,  idiocy,  disturbance  of  sexual  function,  neu- 
roses, psychoses,  epilepsy.  One  sees  that  these  ailments  are  due  di- 
rectly to  the  loss  of  thyroid  function,  and  the  obvious  treatment  is  to 
supply  the  loss..  The  physician  may  hold  the  disease  permanently  in 
check  by  feeding  the  patient  with  preparations  of  thyroid  gland,  while  the 
surgeon  may  succeed  in  improving  or  curing  the  condition  by  implant- 
ing in  the  individual,  normal  thyroid  gland  tissue,  obtained  preferably 
from  man."^  The  implantation  of  parathyroid  tissue  has  not  yet  led 
us  to  definite  therapeutic  knowledge. 

Interesting  as  are  the  results  of  the  loss  of  thyroid  secretion,  the 
results  of  excessive  secretion  are  more  interesting  still.     These  cases  of 
excessive  secretion  are  grouped  under  the  head  of  thyrotoxic  diseases. 
^  Albert  Kocher,  Keen's  System  of  Surgery,  vol.  iii. 


600 


THE    FACE    AND    NECK 


Thyrotoxic  Diseases  [Graves'  Disease;  Basedow's  Disease;  Exoph- 
thalmic Goiter;  H i/p<rthi/r<>idism). — The  cha,racteri«ti('  feature  of  these 
diseases  is  that  the  intoxication  of  the  body  is  effected  through  hyper- 
phisia  of  the  thyroid  gland,  so  that,  as  we  should  expect,  operations 
upon  the  gland  are  almost  invariably  followed  l)y  improvement  in  the 
patient's  symptoms. 

The  symptoms  of  Graves'  disease  are  extremely  numerous,  and  I  shall 
sketch  them  in  the  briefest  detail.  The  thyroid  gland  itself  is  enlarged 
uniformly,  and  one  discovers  in  it  a  thrill,  blowing  murmurs,  expansive 


'v/».  %-^ 


Fig.   394. — External  appearance   of  exophthalinio  goiter   (Massachusetts  General 

Hospital). 

pulsation,  and  enlargement  of  the  artei-ies.  The  growth  is  usually  soft, 
and  there  is  loss  of  elasticity.  The  pulse  is  rapid  (tachycardia)  and  of 
high  tension,  with  commonly  an  increased  blood-pressure.  Slight 
capillary  hemorrhages  are  frequent.  You  will  observe  tremors  of  the 
hands  and  feet,  of  the  eyelids  and  lips.  Bulging  of  the  eyeballs  (ex- 
ophthalmos) occurs  in  acute  cases,  with  lagging  of  the  lids.  The  skin 
is  moist,  the  hair  drops,  the  nails  crack,  there  are  frecjuent  pigmenta- 
tions of  the  skin,  suggesting  Addison's  disease.  Diarrhea  is  common, 
and  there  may  be  nausea  and  vomiting.  There  are  great  lassitude  and 
emaciation,   while  the  menstrual  flow   diminishes  or  ceases  entiiely, 


DISEASE   OF   THE   THYROID   GLAND  GOl 

and  {'hiiracteristic  blood  changes  occur.  Such  arc  a  few  of  the  symp- 
toms. 

Tlie  disease  may  be  acute  or  chronic,  with  acute  exacerbations,  but 
we  need  not  folIo\\'  its  numerous  and  manifold  terms  further  than  to 
observe  that  if  it  develops  suddenly,  the  course  is  more  grave,  and  the 
prospect  more  gloomy  than  when  it  begins  slowly.  With  these  brief  ob- 
servations on  the  nature  of  Graves'  disease  let  us  consider  its  treatment. 

Regarding  the  treatment,  the  most  active  and  diverse  views  are  still 
held.  Many  internists  have  pointed  out  that  almost  any  treatment 
or  no  treatment  at  all  will  result  in  alleviation  or  even  cure,  while  others, 
advancing  upon  more  rational  lines,  have  secured  some  benefit  from 
serum  therapy.  On  the  other  hand,  surgeons,  with  increasing  show 
of  reason,  are  claiming  and  demonstrating  that  resection  of  the  offend- 
ing gland  gives  the  greatest  percentage  of  cures.  I  need  not  here  con- 
sider at  length  the  interesting  problems  of  serum  therapy,  but  refer 
the  reader  to  the  valuable  contributions  of  S.  P.  Beebe  and  John  Rogers.^ 

Of  surgical  treatment,  Albert  Kocher  remarks:  "  To  say  that  this  is 
still  the  best  is  not  enough.  It  has  proved  itself  superior  to  any  other 
form  of  treatment."  C.  H.  Mayo  also,  in  a  series  of  convincing  articles, 
and  drawing  upon  a  great  experience,  has  demonstrated  the  value  of 
these  operations. 

All  cases  of  exophthalmic  goiter  must  not  be  submitted  indiscrimi- 
nately to  operation.  Immediate  operation  should  not  be  done  in  those 
cases  which  show  advanced  cardiac  changes,  irregular  pulse,  low  blood- 
pressure,  or  periodic  attacks  of  delirium  cordis.  In  such  cases  the 
subjects  should  be  submitted  to  x-raj  exposures  and  belladonna  intern- 
ally for  a  few  days  or  weeks  previous  to  the  operation.  Moreover,  it  is 
well  in  such  cases  to  perform  one  or  two  preliminary  ligations  of  the 
superior  thyroid  arteries.  Indeed,  we  believe  that  in  certain  severe  cases 
of  Graves'  disease  the  operation  should  be  performed  in  one,  two,  or 
three  sittings,  beginning  with  tying  the  thyroids.  The  rest  of  the  opera- 
tion must  depend  upon  the  course  of  the  disease  and  the  condition  of 
the  enlarged  gland ;  in  the  case  of  great  enlargement,  one  should  remove 
the  more  vascular  half  of  the  gland  with  the  isthmus  and  pyramidal 
process.  Under  no  circumstances  should  one  remove  the  whole  thyroid. 
In  quite  early  cases  it  may  suffice  for  a  cure  to  ligate  two  or  three  of 
the  thyroid  arteries,  and  in  all  cases  of  resection  of  the  gland  the  sur- 
geon must  avoid  especially  damage  to  the  two  lower  parathyroids  at 
least." 

The  operation  of  thyroidectomy  generally  is  more  difficult  in  Graves' 
disease  than  in  the  ordinary  forms  of  goiter,  for  in  Graves'  disease  the 
vascularity  of  the  tumor  is  greater,  the  vessels  are  more  easily  torn, 
the  external  capsule  is  more  adherent,  and  the  interstitial  tissue  is  more 

1  S.  P.  Beebe,  Jour.  Amer.  Med.  Assoc,  February  17,  1906,  and  Trans.  Amer. 
Med.  Assoc,  1907.  John  Rogers,  Jour.  Amer.  Med.  Assoc,  February  17,  1906.  See 
also  important  paper  by  James  M.  Jackson  and  L.  G.  Mead  on  the  value  of  hydro- 
bromate  of  quinin,  Boston  Med.  and  Surg.  Jour.,  March  12,  1908. 

-  See  G.  W.  Crile's  important  obser\-ations  on  the  Psycliic  Aspects  of  Graves' 
Disease,  Trans.  Amer.  Surg.  Assoc,  1908,  p.  391. 


602  THE    FACE    AND    NECK 

brittlo;  and  these  are  additional  reasons  for  the  occasional  i)i'eliniinaiy 
ligation  of  vessels.  1  shall  have  to  speak  further  of  the  technic  of  the 
operation  when  discussing  goiter  proixM-. 

Until  recently  section  of  the  sympathetic  nerve  occasionally  has 
been  done  as  a  therapeutic  measure  in  Graves'  disease,  but  this  operation 
now  is  generally  abandoned. 

One  need  not  often  fear  extensive  toxic  symi)tonis  following  thyroi- 
dectomy, especially  if  proper  drainage  be  instituted  for  twenty-four 
hours,  and  if  two  parathyroids  at  least  are  left.  In  most  of  the  cases 
the  improvement  in  the  patient's  general  condition  is  prompt  and 
striking.  He  becomes  quiet,  his  eyes  appear  less  wild,  the  ])ulse-rate 
falls,  tremor  disappears,  and  within  a  very  few  days  convalescence  is 
established — conditions  which  contrast  markedly  with  the  results  of 
the  dreary,  prolonged,  and  uncertain  treatment  of  former  times. 

GOITER  1 

Writers  still  speak  of  goiter  as  struma,  but  to  the  student  of  etymol- 
ogy it  is  interesting  to  observe  that  struma  means  ]M-imarily  scrofula, 
and  secondarily  goiter.  Scrofula,  in  the  modern  acceptation  of  the  term, 
means  anything  but  goiter.  Let  us  admit  then  that  goiter  signifies  an 
enlargement  of  the  thyroid  gland,  and  let  us  eschew  the  confusing  term 
struma.  Students  of  the  subject  still  debate  the  question  of  the  classi- 
fication of  goitre,  but  I  believe  we  shall  make  no  mistake  in  adopting 
the  classification  of  Kocher,  bearing  in  mind  always  that  goiter  is  a 
benign  disease,  not  to  be  confused  with  inflammatoiy  swellings  of  the 
gland  or  with  malignant  thyroid  tumors. 

We  divide  goiter  into  two  main  varieties — diffuse  goiter,  in  which  the 
entire  gland  is  involved,  and  nodular  goiter,  in  which  portions  onh-  of 
the  gland  are  affected. 

Diffuse  goiter  occurs  in  six  well-recognized  forms:  (1)  Hypertrophic 
follicular  goiter,  a  genuine  hypertrophy  of  the  whole  gland,  involving 
an  increase  of  all  its  elements;  (2)  parenchymatous  goiter  or  adeno- 
matous goiter,  in  which  the  e])ithelial  cells  only  are  increased  in  number 
and  size ;  (3)  colloid  goiter  (cystic  goiter) ,  due  to  a  stretching  or  enlarge- 
ment of  the  follicles,  which  become  distended  with  colloid  material — 
this  is  by  far  the  most  common  form  of  diffuse  goiter;  (4)  vascular  goiter, 
characterized  by  marked  vascular  changes,  the  arteries  especially  being 
greatly  increased  in  volume.  The  other  elements  of  the  gland  multiply 
also,  but  the  vascular  changes  are  the  most  conspicuous;  (5)  fibrous 
goiter,  a  rare  condition,  due  to  inflammation  and  excessive  development 
of  connective  tissue;  (6)  recurring  adenomatous  goiter,  marked  by  the 
new  formation  of  small  follicles,  and  resembling  adenoma.  Such  growths 
are  properly  malignant,  so  that  the  term  adenoma  malignum  is  employed 
also.     This  is  an  extremely  rare  form. 

Nodular  goiter  also  has  its  six  forms,  corresponding  to  those  of  diffuse 
goiter,  but  portions  or  small  areas  of  the  gland  only  are  involved.  In 
^  Goiter:  French,  goitre;  Latin,  guttur — the  gullet,  the  throat. 


GOITER 


603 


nodular  goiter  also  increase  of  colloid  material  gives  us  the  most  promi- 
nent type,  as  in  variety  number  three,  already  described.  Surgeons 
speak  of  cystic  goiter:  this  form  is  properly  colloid  goiter,  and  the  ap- 
parent cysts  are  the  distended  follicles  filled  with  colloid  material. 
The  reader  will  readily  conceive  how  various  ma}"  be  the  external  ap- 
pearances of  goiter,  depending  upon  the  size,  location,  and  multiplicity 
of  nodules.  Single  isolated  nodules  are  rare.  Sundiy  degenerations 
take  place  in  goiter,  with  the  formation  of  new  tissue  which  may  also 
suggest  at  times  teratomata.  The  enlarging  gland,  if  undisturbed  by 
treatment,  will  continue  to  grow  indefinitely,  as  a  nde,  though  after  the 
patient's  fiftieth  year  many  goitei"s  tend  to  shrink  unless  infianmiation 
or  malignant  changes  supervene. 


Fig.  395. — Cystic  goiter  (TMassaehusetts  General  Hospital). 

Goiter  may  cause  a  great  variety  of  symptoms,  depending  upon 
variations  in  rapidity  of  growth,  in  location  of  the  nodules,  and  in  his- 
tologic stiiicture.  For  a  long  time  there  may  be  no  SATuptoms.  and  the 
patient  will  complain  of  the  deformity  only,  or  there  may  develop  var- 
ious s^Tnptoms  due  to  pressure.  Distortion  of  the  trachea  may  impede 
the  breathing;  pressure  on  the  recurrent  lar^Tigeal  nerve  may  cause 
hoarseness;  the  enlarged  gland  may  push  down  into  the  thorax  and 
alter  the  size  and  relation  of  blood-vessels,  and  the  student  should 
always  remember  the  possibility  of  aberrant  th^Toids  taking  on  goiter 
formation  and  developing  puzzling  tumors  in  unexpected  localities — 
for  instance,  beneath  the  chin  and  at  the  base  of  the  tons;iie. 


604  THE    FACE    AND    NECK 

We  recognize  six  important  facts  in  establishing  the  diagnosis  of 
goiter:  (1)  The  position  of  the  tumor  on  the  fi-ont  of  the  neck,  Ix'low  the 
larynx  and  between  the  sternomastoid  muscles;  (2)  the  up-and-down 
movement  of  the  tumor  during  deep  respiration,  and  especially  during 
the  act  of  swallowing.  If  a  large,  deeply  adherent  goiter  fails  to  move 
with  these  tests,  a  vigorous  cough  will  cause  the  mass  to  protrude,  and 
this  cough  test  is  especially  useful  in  the  case  of  intrathoiacic  goiters, 
which  ordinarily  are  not  readily  visible  or  palpable;  (3)  note  the  easily 
recognized  normal  gland  shape  of  the  diffuse  goiter,  and  the  irregular 
appearance  of  a  nodular  goiter;  (4)  a  goiter  not  fixed  by  infianmiation 
vaay  be  moved  about  readily;  (5)  percussion  and  auscultation  are  most 
useful  in  the  case  of  deeply  placed  goiters,  for  then  one  discovers  char- 
acteristic dulness  behind  the  sternum  and  dulness  along  the  larynx  and 
trachea,  with  diminished  tracheal  breathing  in  the  side  on  which  the 
goiter  lies;  (6)  the  superior  thyroid  artery  and  the  great  vessels  of  the 
neck  often  are  pushed  upward  and  outward  by  the  tumor,  so  that  these 
vessels  become  palpable. 

The  investigator  should  not  overlook  disturbances  of  the  heai't's 
action — disturbances  which  are  common  in  goiter  and  are  of  grave  im- 
portance often.  We  speak  of  goiter  heart,  which  may  be  due  to  inter- 
ference with  the  trachea,  with  the  blood-vessels,  or  with  the  pneumo- 
gastric  nerve.  Such  a  goiter  heart  must  not  be  confused  with  the  toxic 
goiter  heart  or  tachycardia  of  Graves'  disease. 

In  this  necessarily  brief  article  we  cannot  well  study  in  detail  the 
various  manifestations  of  different  forms  of  goiter;  but  sufficient  has 
been  said  to  enable  the  student  to  distinguish  the  three  leading  types — 
diffuse  hypertrophic  goiter,  nodular  adenomatous  goiter,  and  cystic 
goiter. 

The  causation  and  frequency  of  goiter  are  subjects  of  interest 
sufficient  for  chaptei's  of  their  own  in  the  large  surgical  monographs. 
Suffice  it  here  to  point  out  that  our  general  belief  regarding  the  cause  of 
goiter  has  not  changed  during  the  last  three  generations.  The  cause 
appears  to  be  some  peculiarity  of  drinking-water  derived  from  the  soil 
through  which  it  passes;  and  the  peculiarity  of  such  water  is  believed  to 
be  a  qualitative  change  in  the  iodin  which  it  contains.  No  countr}^ 
is  entirely  free  from  goiter  subjects,  though  the  disease  is  especially 
constant  or  endemic  in  certain  countries,  generall}-  mountainous.  These 
cases  of  endemic  goiter  are  generally  of  the  colloid  variety.  Certain  it 
is  that  improvements  in  water-supply  have  made  the  disease  less  fre- 
quent in  famous  goiter  regions. 

It  is  a  fact  familiar  to  surgeons  that  in  great  numbers  of  cases  internal 
medication  suffices  for  the  treatment  of  goiter.  With  medicine,  how- 
ever, we  need  concern  ourselves  no  fuither  than  to  state  that  iodin  is  the 
one  reliable  drug  for  the  relief  of  goiter.  At  one  time  experienced  ph}- 
sicians  maintained  that  90  per  cent,  of  all  cases  of  goiter  could  be  cured 
by  iodin.  This  is  probably  incorrect,  but  the  percentage  is  still  large. 
The  iodin  may  be  given  in  the  form  of  potassium  iodid  or  in  some  of  the 
forms  of  "  soluble  iodin,"  or  the  thyroid  gland  extract  may  be  employed^ 


GOITER  605 

although  this  in  effect  is  but  a  form  of  iodin  administration.  We  have 
to  deal  with  the  operative  treatment  of  goiter,  and  may  note  accordingly 
the  following  conditions  in  which  internal  medication  is  not  appropriate: 
(a)  Nodular  goiter  undergoing  degeneration — a  condition  recognized 
as  gelatinous,  fibrous,  calcareous,  hemorrhagic,  and  cystic;  (b)  diffuse 
colloid  goiter,  which  may  be  attacked  with  iodin,  but  usually  must  be 
referred  to  the  surgeon;  (c)  goiter  causing  pressure  symptoms  and  car- 
diac symptoms;  (rf)  abnormally  situated  goiter,  especially  when  it 
projects  into  the  thorax;  (e)  goiter  developing  suddenly  and  growing 
rapidly,  and  (/)  an}-  goiter  which  is  sensitive  to  pressure  or  spontaneously 
causes  pain.  On  the  other  hand,  there  are  certain  goiters  which  cannot 
safely  be  removed  by  operation — those  which  cause  long-standing 
respiratory  and  circulatory  disturbance,  with  impairment  of  the  vital 
functions.  Nor  should  one  operate  for  goiter  in  persons  with  other 
serious  organic  derangements. 

The  operations  are  various,  and  the  following  six  methods  of  operating 
are  practised :  (1)  Excision;  (2)  enucleation;  (3)  resection;  (4)  combined 
methods;  (5)  exenteration;  (6)  ligation  of  arteries. 

It  seems  needless  to  take  up  in  elaborate  detail  these  various  methods, 
but  the  surgeon  should  have  clearly  in  mind  one  method  at  least,  the 
most  useful  and  the  most  frequently  applicable — excision.^ 

Certain  considerations  appty  to  all  forms  of  operation  upon  goiter. 
The  method  of  anesthesia  has  been  frequentl}-  and  hotly  debated. 
Kocher,  Roux,  and  numerous  other  European  surgeons  employ  local 
cocain  anesthesia  almost  invariably,  and  claim  that  in  thus  dealing  with 
a  sensitive  patient  they  avoid  damage  to  nerves.  One  notes,  however, 
that  Kocher  reports  with  satisfaction  using  general  anesthesia  upon  his 
first  900  cases.  English  and  American  surgeons  commonly  use  chloro- 
form or  ether  for  general  anesthesia,  and  we  hear  little  or  no  complaint 
of  their  results.  We  protest  that  the  cocainized  patients  do  suffer  pain, 
that  the  surgeon  operates  more  comfortably  upon  a  profoundly  anes- 
thetized patient,  and  that,  with  reasonable  care,  he  should  avoid  damage 
to  nerves.  In  a  considerable  experience  I  have  seen  no  reason  to  abandon 
my  own  preference  for  ether  anesthesia.  The  patient  should  be  placed 
in  a  nearly  upright  position,  with  the  head  strongly  extended  over  a 
roller,  and  the  pneumatic  suit  should  be  put  on  ready  for  use  in  case  an 
extensive  operation  is  undertaken,  or  when  there  is  reason  to  suppose 
that  shock  or  hemorrhage  is  to  be  combated. 

Kocher's  method  of  excision  or  a  modification  of  that  method  is  the 
one  most  of  us  follow,  and  the  student  should  remember  always  that  ex- 
cision means  the  removal  of  part  of  the  gland  only.  Total  extirpation  of 
the  thyroid  gland  and  parathyroid  glandules  is  absolutely  unjustifiable, 
for  such  extirpation  means  tetany  and  death  for  the  patient.  Make  a 
transverse  crescentic  incision  from  sternomastoid  to  sternomastoid. 
One  cannot  have  too  much  room  in  which  to  work.     Turn  upward  the 

1  For  an  excellent  description  of  the  common  operations  for  goiter  I  refer  the 
reader  to  J.  F.  Binnie's  luminous  article,  Manual  of  Operative  Surgery,  third  ed.,  pp. 
212  to  221. 


606 


THE    FACE    AXD    NECK 


skin  and  platysma,  ox])osc  the  stenujliyoid,  .steinothyroid,  and  omohyoid 
muscles,  divide  them  if  necessary  (they  should  be  sutured  into  place  later) , 
and  open  transversely  the  external  capsule  of  the  goiter.  This  is  the  loose 
fibrous  capsule  which  readily  may  be  ])eeled  back  in  all  dirtH-lions.  At  the 
same  time  the  surgeon  must  be  on  tlie  lookout  for  the  frecjuent  numerous 
large  veins  which  pass  from  the  capsule  to  the  gland.  These  veins  must 
be  doubly  hgated  and  divided.  Now  dislocate  the  goiter  and  pull  it 
out  of  the  wound,  by  this  maneuver  relieving  pressure  from  the  trachea. 
Before  dislocating  the  goiter  the  surgeon  must  warn  the  anesthetist. 


;?:^ 


*J'* 


Fig.  396. — Cystic  goiter,  dislocated  inward.     Note  severed  sternothyroid  muscle  in 

clamps. 

Next,  doubly  ligate  carefidh"  the  superior  thyroid  artery  and  vein  and 
divide  them  between  the  ligatures.  Pull  the  goiter  over  toward  the 
sound  side,  seek  and  find  the  inferior  thyroid  artery,  which  lies  on  the 
deep  muscles  of  the  neck,  and  tie  it  carefully — carefully,  because  close 
beneath  it  passes  the  recurrent  laryngeal  nerve.  The  thyroidea  ima 
artery  lies  at  the  lower  pole  of  the  tumor  and  must  be  ticnl  finally. 
The  thyroid  isthmus  remains,  and  is  readily  dealt  with  by  crushing  with 
forceps  and  tying  firmly  with  a  linen  ligatui-e.  If  there  be  any  further 
attachments,  they  are  those  which  hold  the  gland  by  its  inner  margin 


GOITER 


007 


with  the  trachea.  Close  at  hand  Hcs  the  recurrent  nerve.  It  is  well, 
therefore,  not  to  rip  off  these  attachments,  but  carefully  to  dissect  away 
the  goiter  at  this  point,  leaving  perhaps  a  little  thyroid  tissue  to  protect 
the  ner\-e.  The  operation  is  now  completed — it  is  not  difficult,  as  a  rule. 
The  surgeon  imites  with  catgut  ligatures  the  cut  superficial  muscles,  and 
sews  up  the  wound  throughout,  providing  at  the  same  time  for  abundant 
tubular  drainage,  the  tube  to  be  removed  at  the  end  of  twenty-four 
hours. 

Such  a  description  of  thyroidectomy  applies  to  removal  of  one  lobe 
only  of  the  gland.  Frequently  it  happens  that  both  lobes  are  extensively 
diseased  or  that  the  patient  is  the  subject  of  exophthalmic  goiter.  In 
such  cases  the  surgeon  must  remove  a  large  part  of  the  second  lobe.     He 


Fig.   39T 


-Operation   of  thyroidectomy   completed, 
muscle. 


Sutures   in   stmnp   and   in 


leaves,  for  the  sake  of  the  thyroid  function,  a  slice  of  gland  adherent  to 
the  posterior  capsule  on  one  or  both  sides.  By  this  maneuver  he  may 
feel  sure  that  he  is  preserving  also  a  sufficient  number  of  parathyroid 
glandules.  Before  slicing  off  the  thyroid  he  should  tie  securely  the 
superior  and  inferior  thyroid  arteries  within  the  substance  of  the  gland. 
After  removing  the  portion  of  the  gland,  it  is  well  to  cauterize  with  the 
Paquelin  cautery  the  cut  surface  of  the  stump. 

After  thyroidectomy  patients  generally  make  a  prompt  convales- 
cence. The  modern  operation  should  not  be  followed  by  severe  symp- 
toms ;  the  patient  should  sit  up  on  the  third  day  and  should  be  able  to 
leave  the  hospital  by  the  middle  of  the  second  week,  with  every  prospect 
of  permanent  restoration  to  health. 


608 


THK    FACE    .VXD    XEf^C 


Enucleation  of  f:;oitcr  occasional!}'  may  be  omploycd  for  the  removal 
of  nodules,  especially  when  the  other  half  of  the  gland  is  atrophied. 
Resection,  after  the  method  of  v.  Mikulicz,  is  useful  in  exceptional  cases  of 
diffuse  goiter,  especially  when  unilateral  excision  has  been  already 
performed  or  the  timior  is  very  large  in  both  inferior  homs.  It  is  a 
rather  dangerous  and  bloody  operation,  and  must  never  be  done  in  cases 
of  Graves'  disease.  Exenteration  (or  marsupiahzation)  means  incision  of 
the  tumor  and  evacuation  of  its  contents.  Exenteration  may  be  em- 
ployed when  there  are  dense  adhesions  present,  and  in  case  of  inflamed 
or  malignant  goiters,  when  a  clean  excision  is  impossible.  Often  we  are 
forced  to  it  in  the  case  of  intrathoracic  goiter,  especial!}-  when  there  is 


Fig.  398. — The  thyroid  orland  and  ])arathyroid   plandulr 
view)  (Halted  and  Evans). 


-supply    ( posterior 


danger  of  asphyxia  and  prompt  relief  is  Imperative.  Ligation  of  the 
thyroid  arteries  is  a  useful  procedure  in  the  case  of  extremely  vascular 
goiters,  and  especially  as  a  preliminary  to  excision  of  the  gland  in  Graves' 
disease. 

Transplantation  of  the  thyroid  has  been  done  in  cases  of  myxedema 
and  idiocy.  The  most  successful  case  of  this  sort  hitherto  reported  is 
that  by  Payr,  to  the  German  Surgical  Congress  in  1906.  Payr  implanted 
a  bit  ot  healthy  thyroid  from  the  patient's  mother  in  the  spleen  of  a  girl 
of  six  years.  Both  patients  recovered  from  the  operation,  and  the 
psychic  condition  of  the  girl  was  improved  at  the  time  of  Payr's  last 
report. 

Satisfactory  as  are  operations  for  goiter,  we  must  not  lose  sight  of 


GOITER  609 

the  fact  that  the  tumor  may  recur  so  long  a.s  the  underlying  cause  of 
the  goiter  formation  persists.  A  "  recurrence  depends  upon  whether 
the  operator  has  removed  the  factors  which  influence  the  growth  of 
the  tumor"  (A.  Kocher).  Diffuse  hypertrophic  goiters  recur  rarely  as 
compared  with  nodular  goiters.  In  general  terms,  however,  we  may 
assort  that  the  recurrence  of  goiter  is  not  common,  but  if  compelled  to 
operate  upon  such  a  recurrent  tumor,  we  shall  find  difficulty  often  in 
dissecting  through  the  mass  of  scar  tissue  and  in  leaving  behind  a  proper 
amount  of  thyroid  gland  with  the  requisite  parathyroids. 

The  thyroid  gland  is  subject  to  sundry  other  affections  far  less  com- 
mon than  goiter. 

Malignant  disease  occurs  in  the  thyroid  gland— rarely,  in  the  normal 
gland,  commonly  in  a  gland  the  subject  of  goiter;  so  that  we  may  prop- 


Fig.  399. — Colloid  goiter  removed  by  author,  leaving  posterior  capsule  and  part  of  left 
lobe  (anterior  view)  (f  actual  size). 

erly  enough  describe  these  growths  as  malignant  degenerations  of 
goiter.  Sarcoma  and  cancer  are  the  malignant  tumors  with  which  we 
are  concerned.  Sarcoma  is  far  less  frequent  than  is  cancer — sarcoma 
of  the  spindle-cell  variety,  less  often  of  the  round-cell  variety.  These 
forms  of  sarcoma  develop  in  nodular  goiter  and  may  be  difficult  to 
distinguish  from  lymphosarcoma.  The  tumor  of  sarcoma  is  soft  and 
juicy.  It  attacks  the  walls  of  adjacent  blood-vessels,  and  it  undergoes 
softening.  Metastases  occur  late,  and  the  sarcoma  kills  slowdy.  There 
are  other  forms  of  thyroid  sarcomata — fibrosarcoma,  osteosarcoma,  and 
angiosarcoma  so  called. 

It  is  not  possible  always  to  differentiate  these  malignant  growths 
from  benign  enlargements  until  the  disease  is  far  advanced.  If  metas- 
tases have  not  occurred,  and  if  the  sarcoma  has  not  broken  through  the 
capsule  proper,  the  tumor  may  be  removed  with  a  reasonable  anticipa- 
tion that  it  will  not  recur. 

39 


61U 


THE   FACE   AND    NECK 


EPITHELIAL  DISEASES   OF   THE  THYROID 

Epithelial  disease  of  the  thyroitl  gland  is  a  fairly  common  disorder. 
Kocher's  classification  includes  the  following  7  forms:  (1)  Genuine  car- 
cinoma, which  appears  as  a  hard  tumor,  usually  lobulated,  the  tissue 
opaque  and  dry,  but  tending  to  undergo  softening,  especialh^  when  it 
develops  in  a  goiter;  (2)  proliferating  goiter  or  malignant  adenoma,  which 
occurs  either  in  nodules  or  diffusely  throughout  the  gland,  while  the 
gland  invariabl}^  contains  portions  of  tissue  of  the  normal  thyroid  type. 
Proliferating  goiter  has  a  firm,  compact  feel  and  is  not  large;  (3)  metas- 
tatic colloid  goiter.  This  is  a  rare  and  curious  growth,  resembling 
closely  the  well-known  nodular  goiter;  (4)  papilloma,  which  may  be  nod- 
ular or  diffuse;  (5)  cancroid  scjuamous  epithelial  cancer — an  extremely 


Fig.  400.— Cancer  of  thyroid  gland  (Halstead). 

rare  disease;  (6)  glycogen-containing  epithelial  goiter — a  growth  which 
develops  in  nodular  goiter  and  grows  rapidly.  The  cells  are  large  and 
contain  varying  amounts  of  glycogen  and  large  nuclei  rich  in  chromatin; 
(7)  small  alveolar  epithelial  goiters,  which  are  quite  similar  to  the  gly- 
cogen variety,  except  that  the  cells  do  not  contain  glycogen.  Classes  t 
and  2  are  far  the  most  common,  and,  when  they  occur,  develop  almost 
invariably  in  hypertrophic  goiters  and  nodular  goiters.  These  cancers 
are  particularly  interesting  from  the  point  of  view  of  treatment.  Often 
unexpectedly,  one  encounters  them  compHcating  a  goiter  presumed 
to  be  benign.  Thyroid  cancer,  like  cancer  elsewhere,  is  marked  by  two 
characteristics — metastasis  and  extension  to  surrounding  structures. 
Unfortunately,  the  presence  of  these  two  features  renders  radical  cure 
impossible,  while  the  diagnosis  is  almost  equally  impossible  before  the 


EPITHELIAL   DISEASES    OF   THE   THYROID  Oil 

development  of  these  two  features.  For  such  reasons,  if  for  no  other, 
the  goiter  of  a  young  adult  should  be  removed  if  its  growth  cannot  be 
controlled  by  iodin.  And,  further,  the  goiter  of  a  middle-aged  person 
invariably  should  be  removed  if  it  is  seen  at  any  time  to  take  on  a  rapid 
growth,  and  particularly  a  rapid  irregular  growth. 

The  treatment  of  malignant  goiter  by  operation  differs  in  no  impor- 
tant essential  from  the  treatment  of  benign  thyroid  enlargement  by 
operation,  except  that  malignant  disease  must  be  removed  more  search- 
ingly.  Here  again  one  encounters  the  problem  of  damage  to  the  parathy- 
roids, and  finds  one's  self  on  the  horns  of  a  dilemma.  If  one  must  choose 
between  complete  thyroid  extirpation  for  cancer  and  partial  thyroia 
extirpation  for  the  sake  of  preserving  parathyroids,  one  may  be  forced 
to  concede  that  no  operation  whatever  should  be  done.  Fortunately, 
however,  this  predicament  arises  rarely,  because  operable  carcinoma 
is  confined  usually  to  one  side  of  the  gland  only.  Far-reaching  opera- 
tions, involving  structures  outside  of  the  thyroid  gland,  have  been  done 
frequently,  but  with  questionable  results.  Surgeons  have  removed 
portions  of  the  trachea  and  the  esophagus,  with  permanent  relief  in  a 
few  cases.  In  one  desperate  case  of  cancer  of  the  thyroid  involving 
the  trachea  I  obtained  a  symptomatic  cure  and  relief  for  six  months  by 
removing  all  involved  tissue  down  to  the  tracheal  wall,  leaving  the  wound 
wide  open,  and  exposing  to  the  direct  Rontgen  ray  the  remnants  of  the 
.disease  daily,  and  with  enough  persistence  to  keep  up  a  mild  derma- 
titis, following  Crile's  method.  At  the  best,  however,  there  is  little  hope 
for  the  cure  of  cancer  developing  in  goiter  unless  the  operation  is  done 
before  the  diagnosis  of  cancer  is  made. 

Aberrant  goiter  exists.  There  are  two  forms:  the  genuine  aber- 
rant goiter,  which  has  developed  in  embryonal  remains  of  the  gland; 
and  false  aberrant  goiter,  which  develops  in  bits  of  gland  secondarily 
and  mechanically  separated  from  the  thyroid.  The  genuine  form 
only  need  concern  us.  You  will  find  the  tumors  in  the  median  line 
always — an  important  diagnostic  point.  They  lie  above  or  below  the 
hyoid,  at  the  base  of  the  tongue  (lingual  goiter),  and  much  more  rarely 
low  down  in  the  neck  or  behind  the  sternum.  The  treatment  of  aberrant 
goiter  depends  much  upon  the  condition  of  the  thyroid  gland  itself. 
If  the  thyroid  be  absent  or  its  function  impaired,  one  may  succeed  in 
curing  the  aberrant  goiter  by  internal  treatment;  but  if  the  thyroid 
gland  be  functionally  intact,  the  aberrant  goiter  had  best  be  excised. 

Diseases  of  the  parathyroids  are  engaging  the  attention  of 
clinicians  and  pathologists  at  this  writing,  and  a  few  cases  of  parathy- 
roid tumors  successfully  removed  have  been  reported. 

Inflammations  of  the  thyroid  gland  are  rare  as  compared  with 
thyroid  tumors,  and  inflammation  of  a  goiter  apparently  i&  less  common 
than  is  inflammation  of  the  normal  gland.  We  need  not  concern  our- 
selves extensively  with  this  subject  further  than  to  observe  that  inflam- 
mations are  acute  and  chronic;  that  when  acute,  they  give  rise  to  the 
familiar  symptoms  of  pain,  heat,  redness,  and  swelling;  and  when  chronic, 
show  slight  enlargements  of  the  gland  with  a  proliferation  of  connective 


612  THE    FACE    AND    NECK 

tissue,  or  present  evidences  of  specific  infection  or  of  tuberculosis. 
The  practitioner  treats  these  inflammations  on  fjeneral  jHinciples — 
with  applications,  Bier  cupping,  opsonic  vaccines,  potassium  iodic!,  and 
incisions. 

In  leaving  the  subject  of  disease  of  the  thyroid  gland  one  reflects 
that  the  topic  is  not  yet  complete,  as  are,  for  example,  appendicitis 
and  disease  of  the  bile-passages,  though  one  feels  more  and  moi'c  strongly, 
as  evidence  accumulates,  that  all  thyroid  disease  is  coming  within  the 
surgeon's  province — especially  nodular  goiter  and  Graves'  disease.  For 
this  reason  surgeons  protest,  as  they  have  long  protested  in  the  case  of 
appendicitis,  that  all  diseases  of  these  organs  should  be  seen  by  a  surgeon 
in  consultation,  for  no  man  may  say  when  or  whether  an  operation  may 
be  necessary.     Thyroid  disease  is  a  surgical  disease. 


PART  VI 

THE  HEAD  AND  SPINE 


CHAPTER  XXIII 
THE  SCALP 


Surgery  of  the  head  and  spine,  by  which  one  understands  especially 
the  surgery  of  the  nervous  system,  is  beginning  to  occupy  a  far  more 
important  place  than  was  thought  possible  less  than  twenty  years  ago ; 
and  those  operators  who  have  followed  the  course  of  the  debate  on  the 
subject  must  have  been  impressed  with  a  radical  divergence  of  views  in 
this  field,  associated  always  with  a  slow  but  steady  progress,  within  the 
ken  of  the  present  surgical  generation.  In  the  later  eighties,  when  opera- 
tions within  the  abdominal  cavity  were  becoming  frequent  and  the  con- 
fidence of  abdominal  surgeons  was  estabUshed,  we  tried  to  believe  that 
an  equally  brilliant  future  awaited  cranial  surgery.  The  belief  was 
founded  upon  our  recently  acquired  appreciation  of  aseptic  surgery. 
Men  began  to  say  that  it  would  be  no  very  serious  matter  to  open  the 
dura,  to  handle  the  brain,  to  explore  its  depths,  and  to  remove  its  tumors; 
while  operations  upon  the  spinal  column  would  increase  likewise  in 
frequency.  Fortunately  or  unfortunately,  the  results  of  endeavors  in. 
neurologic  surgery  were  not  commensurate  with  the  activity  of  enthu- 
siasts. The  death-rate  continued  high,  the  expected  relief  from  syinp- 
toms  was  not  secured  or  was  found  to  be  temporary  only,  and  a  resulting 
skepticism  gradually  was  created  from  which  to-day  only  are  we  be- 
ginning to  recover.  The  painstaking  and  informing  investigations  of 
Waldeyer,  His,  Victor  Horsley,  Harvey  Gushing,  Frazier,  Spiller, 
Walton,  Starr,  and  a  few  others,  are  convincing  the  profession  that  there 
is  a  hopeful  future  in  this  field,  but  that  neurologic  undertakings  are 
far  more  difficult  in  the  diagnosis,  the  inception,  the  performance,  and 
the  after-treatment,  than  are  similar  undertakings  in  the  fiekl  of  abdomi- 
nal surgery.  Each  operation,  when  it  deals  with  the  brain  or  spmal 
cord,  must  be  carefully  planned  and  studied,  approached  with  a  wise 
precaution,  and  carried  through  timely,  elaborately,  accurately,  and  m-. 
telhgently.  Already  we  see  that  the  work  on  the  nervous  system  by 
competent  neurologic  surgeons  is  far  more  effective  than  the  often  crude 
and  hasty  neurologic  work  of  general  surgeons;  and  so  it  becomes  ap- 
parent that,  for  the  present  at  least,  and  until  neurologic  surgery  has 
been  more  highly  developed,  we  must  look  to  special  experts  for  the  best 

613 


614  THE    HEAD    AND    SPINE 

results  in  the  more  obscure,  difficult,  and  hazardous  cases.  Not  that 
one  would  remove  all  head  and  nerve  surgery  from  general  surgeons — 
any  well-ecjuipped  surgeon  should  be  competent  to  open  the  skull,  to 
drain  a  cerebral  abscess,  to  open  the  spinal  canal,  and  to  operate  ujjon 
the  peripheral  nerves;  but  as  yet  the  judicious  observer  cannot  but  feel 
that  the  great  uncompleted  work  on  brain  tumors  and  other  structures 
within  the  skull  is  still  pioneer  work,  and  should  be  delegated  to  specially 
trained  surgeons  so  far  as  they  may  be  found.  A  sei-ious  obstacle  hith- 
erto to  the  more  rapid  and  intelligent  progress  of  neurologic  surgery  is 
the  common  ignorance  of  neurologj-  on  the  part  of  surgeons  and  the  ig- 
norance of  surgery  on  the  part  of  neurologists.  Our  practice  of  referring 
neurologic  cases  to  neurologists,  in  the  first  instance,  who  in  their  turn 
refer  these  cases  to  general  surgeons  for  operation,  must  be  deprecated. 
Our  hope  for  the  future  lies  in  those  surgeons  who  are  versed  in  neurology 
— as  yet  a  small  and  little  appreciated  band. 

Before  advancing  directly  upon  the  great  subject  of  brain  and  nerve 
surgery  it  is  well  to  consider  in  somewhat  conventional  fashion  the  more 
frequent  diseases  and  injuries  of  the  scalp  and  of  the  bones  of  the  head 
and  spine.  More  than  twenty-five  3-ears  ago  Frederick  Treves  published 
his  useful  little  book  on  applied  anatoni}',  the  first  chapter  of  which  deals 
with  the  scalp.  So  well  did  he  exhaust  the  subject  that  nothing  of 
material  intei'cst  has  been  added  to  it  since  his  first  publication.  The 
reader  will  remember  that — 

The  scalp,  or  soft  parts  covering  the  vault  of  the  skull,  may  be 
divided  into  five  layers  (the  skin,  the  subcutaneous  fatty  tissue,  the 
occipitofrontalis  muscle  and  its  aponeurosis,  the  subaponeurotic  con- 
nective tissue,  and  the  pericranium),  and  these  five  layers  have  their 
important  influence  in  limiting  or  directing  injuries  and  infections  of  the 
head.  One  perceives,  therefore,  that  the  skull  has  little  external  pro- 
tection from  violence,  the  onty  buffers  of  account  being  the  thick  tem- 
poral muscles  on  the  sides  of  the  head,  the  heavy  occipital  muscles 
behind,  and  the  bones  of  the  face  in  front.  As  Fowler  observes,  how- 
ever, the  elasticity  of  the  cranial  vault  is  such  that,  on  account  of  its 
peculiar  conformation,  it  may  return  to  its  normal  shape  after  a  severe 
blow,  so  that  a  contusion  only  of  the  soft  parts  may  result. 

CONTUSIONS   OF   THE   SCALP 

Contusions  of  the  scalp  are  of  importance  only  as  they  confuse  diag- 
nosis. A  contusion  is  associated  with  extravasation  of  blood,  and  this 
extravasated  blood  in  the  scalp  is  so  often  sharph-  limited  by  dense 
aponeurosis  or  pericranium  as  to  give  to  the  examiner  the  impression  of 
the  sharp  bony  edge  of  a  fractured  skull.  If  the  surgeon  is  satisfied, 
however,  that  the  lesion  is  a  contusion  onlv,  he  need  fear  no  ill  results, 
and  may  treat  the  disturbance  by  ordering  rest  and  cold  aj^plications.  It 
is  not  too  early  in  this  discussion,  however,  to  remind  the  reader  that  all 
injuries  to  the  head  should  be  regarded  seriously  and  that  the  patient 
should  remain  quietly  under  observation  for  two  or  three  days  at  least. 


CONTUSIONS    OF  THE   SCALP  615 

It  is  our  hubit  at  the  Massachusetts  General  Hospital,  in  the  case  of  a 
head  injury  in  which  there  is  the  slightest  doubt  of  diagnosis,  to  keep 
the  patient  in  the  ward  until  all  suspicion  of  possible  deep-seated  damage 
is  banished. 

Hematoma  of  the  scalp  differs  in  degree  only  from  simple  contusion. 
If  considerable  veins  or  small  arteries  are  torn,  an  abundant  escape  of 
blood  may  occur  beneath  the  aponeurosis  or  skin.  This  may  give 
rise  to  an  extensive  tumor  covering  half  the  head  possibly.  The  blood- 
clot  may  become  infected,  with  a  resulting  abscess  formation.  In  any 
case  if  the  clot  does  not  disappear  within  a  few  days,  the  surgeon  is  justi- 
fied in  opening  freely  through  the  scalp,  washing  out  thoroughly  the 
blood  and  detritus,  and  closing  the  wound  after  providing  for  drainage. 
In  each  case  in  which  such  incisions  are  necessary  the  patient's  head 
should  be  shaved  over  the  area  corresponding  to  the  lesion.  Wounds 
of  the  scalp  heal  rapidly,  for  the  scalp  is  intensely  vascular.  The  drain 
should  be  removed  on  the  second  day,  and  one  should  expect  to  find  the 
line  of  incision  closed  firmlj^  by  the  fifth  day,  when  the  stitches  may  be 
removed.  A  thick,  elastic,  gauze  and  cotton  dressing,  held  in  place  by 
a  head  bandage,  should  be  applied  to  these  wounds,  in  order  to  absorb 
the  discharges,  and  for  the  protection  and  comfort  of  the  patient.  Never 
use  plasters. 

Scalp  wounds  are  the  most  common  of  extracranial  lesions,  and 
every  practitioner  first  and  last  sees  hundreds  of  them.  They  are 
easily  cared  for,  as  a  iiile.  The  familiar  "  broken  head"  of  sporting 
parlance  is  a  contused  scalp  wound  commonly,  and  as  the  head  is  one 
of  the  most  exposed  parts  of  the  body,  it  comes  in  for  all  sorts  of  violence. 
There  is  this  interesting  and  rather  peculiar  fact  about  the  effects  of 
"  cracks  on  the  head " :  a  straight  cleft  or  incised  wound  apparently 
may  be  caused  by  a  blow  from  any  kind  of  implement — a  knife,  saber, 
bludgeon,  brickbat,  parlor  floor,  or  bed-post.  The  scalp  is  so  tightly 
stretched  over  the  cranium  that  a  sharp  blow  with  the  bluntest  instru- 
ment causes  the  skin  to  tear  in  a  fairly  straight  line,  so  that  the  appear- 
ance of  an  incised  wound  is  produced,  though  about  the  wound  there 
msij  be  any  amount  of  tissue  crushed  and  disfigured.  If  incised  wounds 
are  transverse  to  the  anteroposterior  line  of  the  skull  and  penetrate  to 
the  bone,  they  gape.     Longitudinal  wounds  do  not  gape. 

According  to  the  nature  of  the  wound,  so  shall  you  treat  it.  If  it  be 
incised,  check  the  hemorrhage,  clean  the  parts  (after  shaving  the  head 
about  the  lesion),  and  sew  it  up  tightly.  Incised  scalp  wounds  heal 
promptly  because  the  scalp's  blood-supply  is  abundant.  In  two  days 
you  shaU  find  the  union  sound.  If  the  wound  be  contused,  especially 
if  it  be  filled  with  dirt,  it  must  not  be  closed  tightly.  Shave  the  surround- 
ing skin;  cleanse  thoroughly  the  damaged  region;  draw  the  edges  of  the 
wound  together  at  two  or  three  points  with  silkworm-gut  stitches, 
leaving  spaces  for  drainage,  and  apply  a  large  absorbent  dressing. 
In  the  case  of  such  dirty  wounds  remove  the  dressings  frequently  and 
watch  for  eiysipelas  or  extensive  sloughing,  which  must  be  treated  with 
irrigations,  removal  of  necrotic  tissue,  and  fi-esh  clean  dressings  two  or 


616  THE    HKAD    AXD    STIXE 

three  times  a  day.  The  uhiniate  source  of  anxiet}'  in  these  cases  is  a 
possible  extension  of  the  infection  through  the  cliploe  to  the  men- 
inges. 

A  curiously  striking,  shocking,  and  disfiguring  injury  to  the  head  is  a 
complete  scalping, — avulsion  of  the  scalp, — an  accident  confined  to 
women  almost  entirely,  and  to  factory  women,  because  the  long  hair  of 
factory  women  becomes  caught  in  machinery  which  tears  the  scalp  from 
the  head.  The  great  raw  wound  which  results,  in  its  outline  follows 
almost  invariably  the  insertions  of  the  occipitofrontalis  muscle  from  eye- 
brows to  occiput,  and  fi'oni  ear  to  ear.  The  depth  of  the  wound  varies, 
depending  upon  the  abundance  and  strength  of  the  hair.     The  skin  alone 


Fig.  401. — Avulsion  of  the  sralp  ('Massachusetts  Gfucral  Hospital). 

may  be  torn  ofT,  or  all  the  soft  parts  maj'  be  involved  down  to  and  in- 
cluding the  periosteum. 

As  Fowler  points  out,  since  these  accidents  happen  to  anemic  and 
poorly  nourished  women,  as  a  rule,  the  surgeon  should  begin  treatment 
as  soon  as  granulations  have  begun  to  form.  The  only  treatment  of  any 
service  is  Thiersch  grafting,  over  which  the  attendant  must  labor  faith- 
fully until  grafts  sufficient  to  cover  the  entire  head  have  been  taken. 
See  to  it  that  the  grafts  be  not  destroyed  by  needlessly  tight  bandaging. 

TUMORS   OF   THE   SCALP 

Tumors  of  the  scalp  are  extremely  common — especially  benign 
tumors;  and  of  these,  wens  are  far  the  most  frecjuent.     Wens  arc  known 


TUMORS   OF  THE   SCALP 


017 


as  sebaceous  cysts.  They  appear  to  be  epidermal  inclusions,  and  grossly 
on  dissection  arc  found  as  thin-skinned  sacs  filled  with  sebaceous  matter. 
They  are  often  multiple,  develop  in  any  part  of  the  head,  are  movable 
under  the  skin  when  not  inflamed,  and  arc  easily  removed.  They  are 
best  taken  out  through  a  crescentic  incision  incirclmg  the  base.  The 
suro-eon  burrows  under  the  wen  through  this  incision,  lifts  up  the  growth 
with  the  flap,  and  dissects  off  the  wen  from  the  flap.  By  workmg  m 
this  fashion  he  will  get  out  the  whole  of  the  sac,  which  is  essential, 
for  a  portion  of  the  sac  left  behind  may  give  rise  to  a  recurrent  wen. 

Dermoid  cysts  of  the  scalp  resemble  wens,  but  they  are  less  common, 
are  congenital,  and  are  usually  found  along  the  external  portion  of  the 
supra-orbital  arch  and  at  the  fontanels.  The  reasons  for  removing  wens 
and  other  cysts  are  their  increasing  size  and  their  absurd  or  offensive 
appearance. 


Fig.  402.— Neurofibroma  of  scalp  (Valentine  Mott's  case). 

Helmholz  and  Gushing  ^  describe  an  interesting  case  of  neuro- 
fibroma ^  of  the  scalp  (von  Recklinghausen's  disease),  a  rather  rare  con- 
dition giving  rise  to  scalp  tumors,  with  great  relaxation  of  the  scalp,  some- 
times allowing  marked  drooping  of  the  ears  or  showing  as  pendulous, 
down-hanging  masses  from  various  parts  of  the  head.  The_  cure  con- 
sists obviously  in  a  thorough  removal  of  the  tumors  and  excision  of  por- 
tions of  the  scalp.  .    , 

Other  familiar  but  non-malignant  tumors  of  the  scalp  are:  cephal- 
hematoma, lipoma,  horns,  and  meningocele,  a  consideration  of  the  last 
of  which  falls  properly  under  the  subject  of  diseases  of  the  menmges 
(Chapter  XXIV). 

1  H.  F.  Helmholz  and  Harvey  Gushing,  Elephantiasis  Nervorum  of  the  Scalp:  f. 
Manifestation  of  von  Recklinghausen's  Disease,  Amer.  Jour.  Med.  bci,,  beptember, 

^^°^2-Molluscum  fibrosum,  see  J.  Bland-Sutton,  Tumors  Innocent  and  Benign,  fourth 
ed.,  p.  145. 


618  THE    HEAD    AND    SPINE 

Malignant  epithelial  disease  rarely  attacks  the  scalp,  and  when  it 
does  so.  is  generally  in  the  form  of  rodent  ulcer,  extending  from  the  face, 
a  description  of  which  the  reader  will  find  in  Chapter  XX. 

Sarcoma  is  a  rare  disease  of  the  scalp.  It  has  been  observed  oc- 
casionally in  the  occipital  region,  but  is  so  infrequent  that  it  may  be 
regarded  as  a  curiosity  almost. 

A  characteristic  phenomenon  of  the  region  of  the  scalp  is  aneurysm 
— generally  the  cirsoid  or  racemose  variety.  A  simple  aneurysm — a 
circumscribed  dilatation  of  a  portion  of  a  single  vessel — is  very  rare, 
but  cirsoid  aneurysm — a  diffused  dilatation  of  a  number  of  connect- 
ing arteries — is  not  uncommon.  This  curious  aneurysm,  like  varico- 
cele of  the  scrotum,  has  been  compared  to  a  bundle  of  worms.  Its 
appearance  is  striking  and  generally  unmistakable.  The  arteries  are 
enlarged  in  both  circumference  and  length,  and  are  forced  into  an  ex- 
tremely tortuous  or  serpentine  course.  One  makes  the  diagnosis  al- 
most instantly  by  sight,  while  the  touch  confirms  the  impression  of  the 
arterial  character  of  the  disease.  Far  more  rare  than  cirsoid  aneurysms 
are  varices  of  the  scalp,  which  somewhat  resemble  aneurysm,  but  are  less 
tortuous,  are  softer,  and  are  devoid  of  pulsation.  The  cure  of  cirsoid 
aneurysm  is  by  no  means  easy,  and  various  different  attempts  at  a  cure 
have  been  made,  with  more  or  less  success.  The  best  course  probably  is 
that  proposed  by  Dieffenbach,  namely,  to  excise  at  repeated  operations 
portions  of  the  scalp  bearing  the  aneurysm,  allowing  the  wound  to  heal 
each  time  before  operating  again.  Another  excellent  plan,  to  be  adopted 
when  the  aneurysm  is  not  too  large,  is  totally  to  excise  the  aneurysmal 
area,  with  the  skin,  and  fill  in  the  gap  with  skin-grafts.  Whatever  the 
method  employed,  the  surgeon  will  find  the  undertaking  to  present  a  nice 
and  somewhat  puzzling  problem. 

The  practitioner  will  often  encounter  lesions  and  diseases  of  the  scalp 
other  than  those  I  have  enumerated  here,  but  I  have  attempted  in  this 
chapter  to  discuss  those  problems  only  which  are  peculiar  to  the  scalp 
itself. 


CHAPTER  XXIV 

THE  SKULL,  BRAIN,  AND  MENINGES 

Ix  this  chapter  ^ve  shall  consider  an  important  group  of  subjects. 
and  shall  deal  with  regions  and  organs  second  in  importance  to  none 
in  the  body.  Many  surgical  writers  have  treated  of  the  skull  and  brain 
as  separate  entities,  and,  anatomically,  these  structures  are  distinct ;  but 
clinically,  lesions  of  the  brain  and  of  its  bony  covering  are  so  intimately 
associated  that  the  surgeon  must  always  think  of  them  together.  Their 
injuries  and  diseases  often  give  rise  to  a  symptom-complex,  while  opera- 
tions which  deal  with  the  one  concern  the  other  in  great  numbers  of 
cases. 

Surgery  of  the  head  ranks  with  surgery  of  the  long  bones  as  the  most 
ancient  form  of  surgery  in  the  history  of  our  art.  Trepanning  was  prac- 
tised in  remote  prehistoric  times,  as  the  skulls  of  Egyptians  and  Aztecs 
bear  witness,  while  later  Egj-ptian  surgeons,  followed  by  the  Greeks  and 
their  disciples,  the  Romans,  practised  opening  the  skull,  not  only  for 
the  relief  of  fracture  pressure,  but  for  the  cure  of  epilepsy ._  Throughout 
surgical  histor}^  the  records  of  our  best  observers  abound  in  descriptions 
of  head  injuries,  and  of  the  symptoms  and  operations  for  their  relief,  so 
that  at  the  beginning  of  our  0T\-n  generation  abundant  material  was  in 
hand  to  aid  us  in  such  studies.  Those  former  writings,  however,  were  con- 
cerned alwavs  with  a  factor  which  marks  off  ancient  cranial  surgery  from 
our  own.  Sepsis  and  its  results  were  ever-present  complications.  To- 
day, in  considerable  measure,  we  are  not  concerned  with  sepsis,  except 
when  treating  fractures  of  the  base  of  the  skull.  A  cracked  skull  is  a 
smaU  matter  in  itself,  for  cracks  in  the  bones  of  the  head  heal  readily 
and  intrinsically  do  no  special  harm.  We  dread  a  fractured  skull  for 
its  complications  and  results;  for  the  associated  damage  to  the  cranial 
contents. 

Every  general  surgeon  must  deal  with  head  injums,  though  one 
mav  question  the  capacity  of  every  general  surgeon  to  deal  adequately 
with  manv  intracranial  diseases.  Let  us  consider  broadly,  therefore 
certain  important  general  topics:  fractures  of  the  skuU— simple  and 
compound,  depressed  and  non-depressed,  of  the  vertex  and  of  the  base; 
injuries  to  the  brain— pressure,  compression,  hemorrhage,  and  other 
sig-ns  of  cerebral  disorder;  injuries  to  and  inflammations  of  the^men- 
inges;  inflammatoiw  affections  of  the  bones  and  tumors  of  the  bones; 
hernia  and  fungus  'cerebri;  abscess,  tumors,  and  foreign  bodies  withm 
the  skull;  epilepsy,  hydrocephalus,  and  the  methods  of  demonstrating 
and  treating  these  various  profound  lesions. 


619 


620 


THE    HEAD    AND    SPIXE 


FRACTURES   OF  THE   SKULL 

We  are  taught  that  fractures  of  the  skull  group  themselves  nat- 
urally under  four  important  headings — simple,  compound,  non-de- 
pressed, and  depressed.  From  the  earliest  times  a  simple  fracture  of 
the  skull  has  been  taken  to  be  a  relatively  trifling  affair.  It  was  for- 
merly said,  and  is  still  thought  by  many  careless  practitioners,  that  a 
clean  crack  through  the  skull,  without  injury  to  the  skin  or  depression 
of  the  bone,  does  no  special  harm.  In  some  cases  such  a  crack  may  do 
no  special  harm,  but  so  diverse  ai-e  conditions  and  so  undetermined  are 
the  personal  equations  of  patients  that  no  man  may  say,  at  once  or  even 
after  days  and  weeks,  what  will  be  the  outcome  of  a  skull  fracture 
apparently  simple  and  uncomplicated.  The  other  day  a  man,  two  weeks 
convalescent  from  a  crack  on  the  head,  was  leaving  the  Massachusetts 
General  Hospital  to  walk  home.     By  chance  he  was  met  at  the  door  of 


Fig.  403.— Skull  indented  without  fracture  (Ma.ssacliu.sells;  General  Hospital). 

the  ward  by  the  visiting  surgeon,  who  noticed  a  suspicious  uncertainty 
in  the  man's  steps.  The  surgeon  countermanded  the  order  for  discharge 
and  sent  the  man  back  to  bed.  That  night  the  patient  lapsed  into  un- 
consciousness and  was  dead  within  a  week.  At  the  postmortem  a  large 
area  within  the  skull  was  found  to  be  occupied  by  blood-clot  and  dis- 
organized brain.  The  obvious  skull  damage  was  of  no  moment,  but  the 
concealed  damage  was  fatal.  Harvey  Cushing  gives  us  an  interesting 
story  of  a  young  man  who  was  tilted  out  of  the  back  seat  of  a  wagon  and 
fell  upon  his  occiput.  His  physician  could  find  no  evidence  of  external 
injury,  and  treated  the  case  lightly  as  a  probable  simple  fracture  without 
depression;  but  undoubtedly  there  was  consideiable  local  hemorrhage 
between  the  bone  and  dura.  At  any  rate,  after  two  months  the  patient 
became  an  epileptic,  and  finally  a  year  later,  when  he  was  operated  upon, 
the  surgeon  discovered  an  adherent  dura  and  a  depressed  scar  over 
Broca's  convolution.     An  experience  of  such  cases  gives  one  pause,  and 


FRACTURES    OF   THE    SKULL 


G21 


leads  to  the  conviction  that  any  persistent  sj'mptoms  of  intracranial 
damage  call  for  a  trephining  and  exploration  within  the  skull. 

Such  considerations  will  suggest  to  the  reader  the  extreme  difficulty 
of  making  a  prompt  and  exact  diagnosis  of  head  injuries,  and  will  indi- 
cate also  the  uncertainty  of  the  surgeon  when  he  comes  to  their  treat- 
ment. The  unique  conformation  of  the  skull  adds  to  the  difficulty  of 
diagnosis,  for  in  the  skull  we  have  to  deal  with  an  outer  table,  a  diploe 
(corresponding  to  the  medullary  cavity  of  long  bones) ,  and  an  inner  table. 
In  the  case  of  a  simple  fracture  it  may  be  possible  to  determine  the  extent 
of  the  injury  by  touch  or  by  consideration  of  the  immediate  S3^mptoms. 
Moreover,  in  young  children,  after  an  injury,  there  may  exist  a  depression 
of  the  skull,  without  fracture,  corresponding  to  the  so-called  green-stick 


Fig.  404. — Incircling  fracture  of  the  skull  (Keen's  Surgery). 

fracture  in  the  long  bones.  While  a  simple  crack  of  the  outer  table 
is  harmless  enough,  it  is  often  impossible  to  say  whether  or  not  the  inner 
table  be  damaged  also,  and  we  know  that  a  trifling  lesion  of  the  outer 
table  often  is  associated  with  an  extensive  lesion — splintering  and 
depression — of  the  inner  table. 

One  must  distinguish  also  the  difference,  often  vital,  between  simple 
fracture  of  the  vault  and  fracture  of  the  base  of  the  skull,  bearing  in  mind 
always  that  the  two  maj^  be  associated,  on  the  one  hand,  as  independent 
lesions,  or,  on  the  other,  as  a  continuous  lesion,  in  as  much  as  a  crack 
beginning  in  the  base  mary  run  around  to  the  vault  (fracture  by  exten- 
sion) partially  or  entirely  incircling  the  skull.  Conventional  writings 
describe  independent  fractures  of  the  vault  and  independent  fractures  of 


622  THE   HEAD   AND   SPINE 

the  base,  but  clinicallj'  one  may  not  always  draw  such  a  distinction 
between  these  two  fractures. 

Most  fractures  of  the  vault  are  due  obviously  to  direct  violence — to 
a  bloAV  or  fall  upon  the  head — and  these  causes  of  injuiy  arc  evident 
enough ;  but  one  variety  of  fracture  of  the  vault  deserves  special  mention 
— the  punctured  fracture.  Kecently  I  was  asked  by  a  physician  to  see  a 
little  boy  whose  history  of  injury  ran  somewhat  as  follows:  Twenty-four 
hours  before  I  saw  him  he  was  playing  in  a  street  trench  which  was 
being  excavated  for  the  laying  of  pipes.  In  the  midst  of  his  play  he  ran 
home  with  a  thin  stream  of  blood  trickling  through  his  hair,  and  told  how 
a  heavy,  sharp-pointed  spike  had  fallen  upon  the  top  of  his  head.  The 
physician  who  was  called  thought  little  of  the  matter  at  first,  but  became 
alarmed  after  a  few  hours  when  the  boy  lapsed  gradually  into  uncon- 
sciousness. I  opened  the  skull  and  showed  the  condition  to  be  one 
of  punctured  fracture  of  the  inner  table,  with  laceration  of  the 
meninges  and  brain,  and  extensive  intracranial  hemorrhage  with 
meningitis. 

The  cause  oi  fracture  of  the  base  of  the  skull  is  not  always  so  obvious. 
Commonly,  basal  fractures  are  independent  of  fractures  of  the  vault. 
We  used  to  hear  of  fracture  by  contrecouj),  and  of  fractures  due  to  a  com- 
pression and  bursting  force,  but  these  explanations  of  basal  damage 
and  fracture  no  longer  are  held  tenable,  and  physicists  have  come  to 
accept  Aran's  theory  of  irradiation,  j^erhaps  with  modifications,  as  ex- 
plaining fracture  opposite  to  the  side  on  which  the  blow  fell.  Cer- 
tain it  is  that  in  many  cases  force  exerted  upon  one  side  of  the  head 
demonstrates  itself  by  a  lesion  on  the  opposite  side — at  the  base  or  else- 
where. However,  direct  violence  is  by  far  the  most  common  cause  of 
basal  fracture — direct  violence  Q,pplied  either  from  above  or  below.  A 
crushing  force  descending  from  above  maj'  crowd  the  base  down  upon 
the  spinal  column;  or  a  man  falling  from  a  height  and  landing  on  his 
feet  may  have  his  skull  driven  down  and  crushed  at  the  base,  in  the  same 
manner  as  when  a  carpenter  forces  down  the  head  of  his  hammer  by  strik- 
ing its  handle  upon  the  bench.  A  fracture  of  the  base  is  more  apt  to  be 
compound  than  simple.\  A  glance  at  a  skull  will  remind  the  reader  that 
its  base  is  divided  intoJhree.fosssD — the  anterior  fossa,  marked  by  the 
Jesser  wing  of  the  sphenoid ;  the  middle  fossa,  bounded  by  the  lesser  wing 
of  the  sphenoid  in  front  and  the  petrous  bone  feeliiiid;  and  thejioatcriox 
fossa,  extending  from  the  petrous  bone  to  the  Jateral  sinus  behind,  and 
containing  the  whole  of  the  foramen  magnum  and  basillar  process. 
From  this  arrangement  of  parts  the  student  will  perceive  that  simple 
fracture  of  the  base  of  the  skull  occurs  in  the  posterior  fossa  only. 
Fracture  of  the  anterior  fossa  becomes  at  once  compound  through  open- 
ing into  the  sphenoid  sinuses  or  upper  nasal  passages,  so  that  blood 
and  cerebrospinal  fluid  escape  through  the  nasfii  Fracture  of  the  middle 
fossa  nearly  always  involves  the  petrous  bone,  and  so  becomes  compound 
by  communication  with  the  outer  air  through  the  jxtemjj  auditor}'-  canal, 
by  which  blood  and  cerebrospinal  fluid  escape;  but  fracture  of  the  post- 
erior fossa,  unle^the  basilar  process  be  broken  and  the  pharynx  be 


FRACTURES   OF   THE    SKULL  623 

opened,  remains  simple,  so  that  extravasatcd  blood  shows  itself  late, 
under  the  skin  only,  below  thejiLaaJLoiLLprocess. 

Coticpound  fracture  of  the  vault  differs  from  simple  fracture  of  the 
vault  in  no  material  fashion,  so  far  as  anatomic  changes  are  concerned, 
except  that  in  compound  fractures  the  damaged  bone  and  deeper  parts 
are  exposed  to  the  air  through  the  rending  of  the  soft  pai-ts,  so  that  there 
results  often  septic  infection  of  the  brain  and  its  coverings. 

The  characteristics  of  skull  fractures  vary.  There  may  be  a  simple 
crack  of  the  outer  table  or  of  both  tables;  there  may  be  splintering  of  the 
bone  into  sundry  fragments ;  and  there  may  be  depression  of  the  broken 
bone,  fragments  being  driven  in  and  made  to  impinge  upon  the  meninges 
and  brain.  The  meninges  may  be  torn,  the  brain  may  be  lacerated,  arte- 
ries and  veins  may  be  divided,  hemorrhage  may  take  place  within  the 
skull  where  the  blood  may  lie  compressing  the  brain,  or  the  blood  may 
make  its  way  outward;  while  an  extensive  edema  of  the  brain  itself — 
the  result  of  its  rough  treatment — may  become  established. 

With  this  understanding  of  the  appearance  of  fractures  of  the  skull 
— of  the  vault  and  of  the  base,  simple  and  compound — let  us  now  consider 
the  vital  consequences  wdiich  may  follow  these  head  injuries;  bearing  in 
mind  always  that  whereas  the  symptoms  due  to  simple  fracture  are 
dependent  on  pressure  and  possible  laceration,  in  compound  fracture,  on 
the  other  hand,  there  are  added  often  to  these  symptoms  the  grave 
evidences  of  sepsis. 

The  symptoms  and  signs  of  simple  fracture  of  the  vault  are  elu- 
sive. It  is  by  no  means  easy,  always  and  at  once,  to  determine  the  pres- 
ence of  a  vault  fracture,  because  bruising  and  swelling  of  the  soft  parts 
may  so  mask  the  damage  to  the  bone  that  one  cannot  accurately  feel 
the  fracture.  In  such  case  the  surgeon  may  conclude  that  he  had 
best  wait  for  subsidence  of  the  swelling  or  the  development  of  later 
symptoms  before  making  his  diagnosis.  The  a:-ray  may  decide  the 
question.  On  the  other  hand,  extensive  fracture  with  marked 
depression  of  the  bone  may  be  instantly  obvious.  Should  the 
patient's  condition  be  at  all  serious — that  is  to  say,  should  there  be 
present  unconsciousness  or  other  evidences  of  cerebral  disturbance — 
the  surgeon  had  best  turn  back  a  flap  of  soft  parts  so  as  to  determine 
the  condition  of  the  skull.  Compound  fracture,  on  the  other  hand,  can 
be  made  out  easily,  for  through  the  rent  in  the  soft  parts,  enlarged,  if 
necessary,  the  surgeon  may  introduce  his  gloved  finger  and  feel  the 
broken  bone,  taking  pains  alw^ays  not  to  mistake  normal  suture  lines  and 
Wormian  bones  for  a  fracture. 

Beyond  the  signs  demonstrated  through  digital  exploration  there 
are  sundiy  other  evidences  which  may  lead  one  to  the  conclusion  that 
serious  internal  damage  exists,  and  we  shall  now  consider  some  of  the 
classic  symptoms  of  head  injury. 

Concussion  of  the  brain  may  or  may  not  be  associated  with  frac- 
ture. Doubtless  concussion  is  in  itself  a  genuine  entity,  which  alone 
may  cause  death,  or,  when  associated  with  obvious  brain  lesions,  may  be 
a  contributory  cause  of  death.     Since  1677,  when  Borel  first  described 


624  THE   HEAD   AND   SPINE 

concussion,  the  word  has  been  familiar  to  surgeons,  though  their  defi- 
nition of  concussion  frequcntl}'  has  changed.  \\'e  regard  concussion  us 
a  positive  condition,  not  anatomically  demonstrable,  not  to  be  con- 
fused with  contusion,  compression,  and  laceration.  A  concussion  of 
the  brain  results  from  a  heavy  blow  or  a  series  of  light  blows  on  the 
skull,  and  the  experiments  of  Kocher,  as  explained  further  by  Tilhnan, 
enable  us  to  formulate  the  hypothesis  that  the  violence  inflicted  upon 
the  skull  is  transmitted  to  the  brain,  which,  inclosed  in  its  air-tight  cap- 
'  sule  of  bone,  is  set  in  motion  by  the  force  of  the  blow.  Since  the  white 
brain  substance  is  of  a  higher  specific  gravity  than  the  gray,  it  continues 
in  motion  for  a  longer  time  than  the  gray,  with  a  h3pothetic  resulting 
distortion  along  the  boundary  between  gray  and  white  matter,  which 
causes  the  loss  of  consciousness.^  This  explanation  of  concussion  sug- 
gests that  the  distinction  between  concussion  and  contusion  is  one  of 
degree  only — indeed,  Kocher  assumes  that  concussion  is  a  form  of  con- 
tusion, and  proposes  to  drop  the  word  concussion  from  surgical  literature. 
However,  since  a  contusion  is  commonly  associated  with  actual  and 
obvious  anatomic  changes,  and  since  concussion  is  not,  it  seems  well 
to  the  writer  to  retain  the  old  word. 

Concussion  gives  us  a  distinct  chnical  picture.  The  patient  is  im- 
coDscious;  he  appears  to  sleep;  he  breathes  rapidly  or  irregularh* ;  his 
pulse  becomes  slow,  sinking  to  40  or  even  less,  but  if  the  patient  dies  at 
this  stage,  the  pulse  rises  and  flickers  toward  the  end.  If  he  recovers, 
it  rises  slowly  and  strongly.  In  slight  degrees  of  concussion  the  un- 
consciousness may  be  less  marked,  or  so  transient  as  to  escape  obser- 
vation. There  exist  pallor  and  vomiting  also,  but  the  vomiting  occurs 
once  only,  as  a  rule.  There  are  often  profound  vasomotor  distui-bances. 
The  reaction  comes  gradually ;  early  or  late,  when  consciousness  returns, 
the  face  becomes  reddened  and  the  pulse  grows  full  and  strong.  This 
stage  of  reaction  is  sometimes  followed  bj'  glycosuria,  poljairia,  and 
albuminuria. 

A  favorite  old  examination  question  for  medical  students  is — dis- 
tinguish between  concussion  and  compression  of  the  brain. 

Compression  of  the  brain  implies  a  distinct  anatomic  change 
within  the  skull — the  presence  of  some  unwonted  substance  pressing 
upon  and  crowding  the  brain  from  without.  As  Dennis  has  pointed  out, 
one  must  not  confuse  the  terms  compression  and  pressure.  Compression 
may  be  due  to  an  effusion  of  fluid  (blood  or  cerebrospinal  fluid)  beneath 
the  skull,  pressing  upon  the  brain,  a  condition  usually  resulting  from 
traumatism,,  the  rupture  of  a  blood-vessel,  or  from  depressed  bone. 
Pressure  (intracranial  pressure)  is  due  to  a  force  acting  from  within  the 
brain.  For  instance,  a  growing  tumor,  or  the  collection  of  fluid  within 
the  ventricles,  may  raise  greatly  the  intracranial  tension  and  so  give 
rise  to  pressure  symptoms.  It  must  be  obvious  that  the  compression 
exerted  by  a  mere  depression  of  bony  fragments  is  not  likely  to  cause 
immediate  and  profound  symptoms  unless  there  be  associated  damage 
to  the  brain,  with  extensive  escape  of  fluid,  or  cerebral  edema.  The 
^  Von  Bergmann,  System  of  Surgerj^,  American  edition,  vol.  i,  p.  186. 


FRACTURES   OF  THE    SKULL 


625 


symptoms  which  occur  in  compression  are  probably  clue  to  the  flowing 
out  of  cerebrospinal  lluid  from  the  meningeal  spaces  into  the  general 
ventricular  cavity,  into  the  spinal  meninges,  and  by  the  opening  of  the 
inferior  boundary  of  the  fourth  ventricle.     Aon  Bergmann  pointed  out 
that,  by  the  removal  of  this  fluid  support  from  the  brain  in  the  area 
where  the  large  vessels  enter,  direct  sj'stoUc  impressions  are  conveyed  to 
the  cerebral  mass.     We  have  seen  how  the  acute  cerebral  disturbances 
of  concussion  are  clue  to  mechanical  violence,  apparently  affecting  the 
brain  in  all  its  parts.     In  compression,  on  the  other  hand,  the  cerebral 
disturbances  are  not  due  directly  to  the  traumatism,  but  to  a  secondary- 
slowing  of  the   circulation.     In  other  words,  the  symptoms  of  com- 
pression of  the  brain  are  the  result  of  a  retarded  circulation  of  fresh  oxy- 
genated blood.     Cerebral  anemia  results.     This  slowing  of  the  circula- 
tion, associated  with  the  faU  in  the  pulse,  checks  the  activity  of  the  cen- 
tral nervous  svstem.     There  result  certain  characteristic  symptoms,  and 
these  sympt'oms  are  to  be  divided  clinically  into  two  stages:  the  stage^  of 
stimulation  and  the  stage  of  parahjsis.     That  first  stage  of  stimulation 
appears  to  be  due  to  (Kocher)  a  compensatory  rise  of  blood-pressure, 
which  foUows  immediately  upon  the  early  increase  of  intracranial  ten- 
sion.    In  that  stage  the  patient  complains  of  headache,  and  he  vomits; 
he  is  restless,  delirious,  with  a  flushed  face  and  contracted  pupils,  while 
at  the  same  time  the  observer  finds  with  the  ophthalmoscope  choked 
disk:  and  the  Riva  Rocci  apparatus  shows  a  constant  rise  of  blood-pres- 
Fure."  while  the  pulse  slows.     AfterT\-ard  there  comes  the  stage  of  paraly- 
sis.    Increasing  pressure  within  the  skuU  causes  increasmg  cerebral 
anemia ;  stupor  and  unconsciousness  deepen  into  coma.     The  respiration 
becomes  stertorous  and  of  the  Cheyne-Stokes  type;  the  pulse  becomes 
rapid  and  soft :  feces  and  urine  are  passed  involuntarily,  the  breathmg 
becomes  more  or  less  irregiilar  until  it  ceases,  the  heart  beating  for  several 
minutes  after  the  respiration  has  stopped,  until  death  ensues. 

It  is  worth  our  while  briefly  to  consider  in  some  detail  these  various 
s^Tnptoms.  The  headache  h  instantly  present,  growing  more  mtense, 
alwavs  persistent,  rarelv  localized,  and  is  easily  aggravated  by  motion 
or  by  external  pressure.  The  vomiting  is  sudden,  spontaneous,  and  not 
preceded  bv  nausea.  It  is  more  persistent  than  the  single  act  of  vomit- 
ing seen  in  cases  of  concussion.  Headache,  vomiting,  and  blindness 
compose  the  trioloov  indicative  of  serious  intracranial  disturbance  of 
whatever  origin,  and  we  have  seen  that  the  choked  disk  leading  to  blind- 
ness frequently  results  from  traumatic  compression.  In  the  early  stage 
of  compression  the  patient  is  constantly  restless,  rolling  his  head,  groan- 
ing, and  tossing  his  body.  As  the  stage  of  paralysis  suiperxenes  the  pulse, 
hitherto  slow.'^becomes  rapid— a  most  unfavorable  sign,  indicating  an 
approaching  paralvsis  of  the  vagus.  In  the  stage  of  stimulation  the 
pupils  are  contracted,  but  later,  with  coma,  the  pupils  become  widely 
dilated,  as  a  mle:  though  rarely,  and  as  a  result  of  some  special  localirn- 
tation,  thev  mav  varv.mav  contract  and  respond  slowly,  if  at  all.  to  hght. 
Note  the  condition  of  the'conjunctival  reflex:  if  that  is  gone,  the  pupils 
will  not  react  to  light.     The  condition  of  the  pupils,  as  I  have  described 


40 


02G  THK    HKAD    AND    SPINE 

it,  applies  especially  to  cases  of  general  intracranial  pressure,  but  a 
further  anil  confusing  situation  arises  when  conijjression  is  exertetl  u))on 
a  portion  of  one  cerebral  hemisphere  only.  In  such  a  case  the  pupil  on 
the  affected  side  is  wont  to  be  dilated  and  motionless  even.  Choked  disk 
begins  early,  and  continues  to  the  end  if  the  patient  does  not  recover, 
and  choked  disk,  if  present  while  the  patient  is  unconscious,  and  if  long 
enough  continued,  leads  to  blindness.  Unco7tsciousncss  may  come  on 
suddenly  or  gradually  and  may  be  partial  or  complete.  Sudden  uncon- 
sciousness is  due  to  concussion  or  to  apoplexy.  A  slowly  increasing 
hemorrhage  causes  gradual  unconsciousness.  Stupor  does  not  signify 
complete  unconsciousness,  for  the  patient  in  stupor  may  be  roused  to 
recognize  his  surroundings.  Profound  coma  implies  complete  uncon- 
sciousness, the  impossibility  of  being  roused,  abolition  of  the  reflexes 
(which  may  have  been  active  in  the  earl}'  stages  of  compression),  flaccid 
muscles,  incontinence  of  feces,  and  incontinence  or  retention  of  urine. 
The  temperature  is  significant.  For  a  short  time  after  a  head  injury  the 
temperature  is  alwaj'S  subnormal,  indicating  a  condition  of  pronounced 
shock  in  which  the  patient  may  die.  If  the  patient  reacts  from  shock, 
the  temperature  rises,  ascending  many  degress — up  to  105°,  106°,  or 
107  °  F.  This  steady  rise  is  a  grievous  sign.  In  other  cases  the  tempera- 
ture reaches  a  moderate  height  and  there  remains,  marking  time  for  a 
while.  Its  subsidence  is  a  favorable  sign;  its  subsequent  rise,  a  fatal 
sign.  These  variations  of  the  temperature — subnormal,  high,  and  stead- 
il}'  rising,  and  moderate  without  variation— are  important  prognostic 
signs.  The  nervous  phenomena  are  extremel}-  interesting  in  cases  of 
pressure  and  compression.  If  the  compression  be  sudden  and  excessive, 
there  results  always  coma  without  voluntary  movement.  General 
paralyses  or  paralysis  of  one  side  only  (hemiplegia)  may  be  present  and 
depend  upon  the  site  and  extent  of  the  head  injury.  A  general  and  ex- 
cessive compression  of  the  brain  or  the  intrusion  of  a  foreign  mass,  such 
as  a  blood-clot,  between  the  brain  and  the  bone  at  the  base  accounts 
for  the  symptoms  of  general  paralysis.  The  presence  of  a  foreign  mass 
at  one  point,  either  over  the  vertex  or  at  the  base,  without  excessive 
general  compression,  gives  rise  to  special  localized  nervous  phenomena, 
such  as  accentuated  reflexes  at  first  from  overstimulation,  followed  later 
by  local  paralysis  as  the  pressure  increases  or  is  prolonged.' 

The  course  of  the  symptoms  depends  upon  their  cause,  and  whether 
the  pressure  be  exerted  continuously,  or  be  modified  or  relieved.  One 
perceives,  therefore,  that  continued  bone  depression  produces  per- 
manent and  constant  encroachment  on  the  cavity  of  the  skull;  extra- 
vasated  blood  may  increase  in  volume  so  as  to  destroy  life  by  compres- 
sion, or  the  hemorrhage  may  be  checked,  or  the  blood  may  escape  out- 
ward; an  abscess  rapidly  forming  progresses  continuously  and  causes  con- 
stantly increasing  pressure.  The  surgeon,  therefore,  must  watch  care- 
fully the  symptoms  to  determine  whether  pressure  is  increasing,  is 
stationary,  or  is  diminishing.  Lapse  of  time  after  the  beginning  of 
pressure  S3'mptoms  is  another  important  factor  in  the  problem.  A  high 
1  L.  B.  Rawling,  Lancet,  April  9,  16,  23,  1904. 


FRACTl  RES   OF   THE   SKULL 


627 


degree  of  pressure,  lasting  for  a  short  time  and  then  relieved,  may  not 
kill  the  patient,  while  a  persistently  moderate  pressure  eventually 
may  destroy  the  individual,  and  one  must  remember  that  persistent 
pressure  leads  to  increasing  cerebral  edema  and  a  consequent  further 
increase  of  tension.  There  is  one  common  and  most  serious  cause  of 
compression  which  demands  some  further  consideration: 

Hemorrhage. — Let  the  reader  remember  that  intracranial  hemor- 
rhage ma}'  be  either  traumatic  or  spontaneous.  The  vast  majoiity 
of  spontaneous  hemorrhages  come  from  the  lenticulostriate  artery  and 
cause  apoplexy,  a  disease  within  the  province  of  the  physician,  in  most 
cases.  We  have  to  consider  here  traumatic  hemorrhage,  in  which-  the 
commonest  source  of  bleeding  is  one  of  the  branches  of  the  middle 
meningeal  arter}-.  An  uncommon  source  of  bleeding  is  a  torn  sinus,  or 
there  may  be  a  rupture  of  one  of  the  small  vessels  in  the  pia.  The  middle 
meningeal  artery  is  a  branch  of  the  internal  maxillary,  in  its  turn  one  of 
the  main  divisions  of  the  external  carotid.  The  middle  meningeal  enters 
the  skull  through  the  foramen  spinosum,  divides  into  three  branches, 


^^fe 

^ 

\ 

'«f-?' 

Fig.  405. — Fracture  of  the  inner  table 
with  outer  table  intact  (Campbell) . 


Fig.  -106. — Fracture  of  the  outer  table 
with  the  inner  table  intact  (Campbell) . 


and  passes  up  on  the  inner  surface  of  the  cranium,  which  it  furrows 
deeply,  lying  outside  of  the  dura.  This  extradural  position  of  the  middle 
meningeal  is  important  and  significant  in  the  case  of  head  injuries,  for 
damage  of  the  middle  meningeal  causes  extradural  hemorrhage.  Now 
there  are  three  forms  of  traumatic  intracranial  hemorrhage:  (1)  Extra- 
dural; (2)  subdural  (between  the  dura  and  the  brain),  and  (3)  cerebral 
(within  the  brain  substance).  Extradural  hemorrhage  is  probably  the 
most  common  form  seen  in  accident  surgery,  and  the  fashion  in  which  the 
patient  was  hurt  seems  to  have  little  bearing  on  the  production  of  hem- 
orrhage.  Splintering  and  depression  of  the  bone  are  not  necessary. 
A  short^  time  ago  I  saw  in  the  accident  room  of  the  Massachusetts  Gen- 
eral Hospital  a  boy  of  ten  who  had  been  struck  above  the  left  ear  by  a 
carriage-pole  some  two  hours  before  he  was  brought  to  the  hospital.  He 
had  been  knocked  down  and  dazed,  had  risen,  vomited,  and  staggered 
(concussion) ;  he  had  walked  home,  where,  as  his  mother  told  me,  he 
suffered  from  twitching  of  the  left  arm  and  became  stupid.  He  was 
brought  into  the  hospital.  When  I  saw  him  he  was  in  a  state  of  increas- 
ing stupor,  as  the  house  surgeon  testified  ;  his  left  arm  and  leg  were  in  a 


628 


THE   HEAD    AND   SPINE 


state  of  paresis;  both  pupils  were  contracted  and  failed  to  react;  the 
pulse  was  slow  and  hard,  with  tension  of  ISO,  and  tiie  whole  condition 
was  obviously  one  of  increasing  cerebral  compression  from  hemorrhage. 
There  was  a  slight  bruise  over  the  left  ear,  but  no  palpable  evidence  of 
fracture  there.  The  reader  \\ill  observe  that  the  kjcal  symptoms  of 
paresis  were  on  the  left  side,  indicating  a  cortical  brain  disturbance  on 
the  right  side.  I  relate  these  facts  in  order  to  show  how  a  severe  and 
alarming  lesion — a  rupture  of  the  middle  meningeal  artery — may 
arise  without  direct  violence  to  the  affected  artery.  In  this  boy's  ca.se 
the  damage  was  by  cont  ccoup,  as  we  still  say.  The  blow  upon  the 
left  side  of  the  head  had  ruptured  a  blood-vessel  on  the  right  side.  The 
subsequent  conduct  of  the  case  was  obvious,  and  the  course  satisfactory. 
The  skull  was  opened  over  the  anterior  branch  of  the  right  meningeal 
artery;  the  torn  vessel  was  found  and  tied;  an  extensive  extradural 
blood-clot  was  washed  out;  the  patient's  symptoms  improved  instantly, 
and  eventually  he  recovered.  This  story  demonstrates  a  possible  but 
somewhat  infre^iuent  cause  of  meningeal  hemorrhage — indirect  violence. 


Fig.  407. — Both  tables  fractun-d  and  de- 
pressed (Campbell). 


Fig.  408.- — Compression  of  the  brain 
caused  by  collection  of  blood  or  pus 
between  tlie  bone  and  the  dura  mater 
(Campbell). 


A  far  more  common  cause  is  direct  violence,  with  crushing  of  the  skull 
over  the  vessels,  and  a  tearing  of  the  artery  by  splinters  of  bone.  In 
either  case  unconsciousness  may  be  delaA'ed,  so  that  stupor  and  coma  are 
late  symptoms,  provided  the  initial  violence  has  caused  no  marked 
concussion.  With  the  enlargement  of  the  clot  toward  the  base  the  pupil 
on  the  same  side  ceases  to  react  to  light,  becomes  motionless,  and  di- 
lates widely,  while  if  the  clot  be  on  the  left  side,  aphasia  occurs.  Then, 
with  the  continued  bleeding,  other  cortical  centers  are  involved.  The 
face  becomes  paralyzed,  and  there  follows  parah^sis  of  the  arai,  and 
finally  of  the  leg,  as  the  blood-clot  extends  up  over  the  vertex.  Con- 
vulsions are  rare;  the  pulse  becomes  slow,  sti'ong.  and  full:  the  breathing 
labored  and  irregular,  while  the  temperature  falls  at  first  and  then  rises, 
as  I  have  already  described  it.  Should  the  fracture  be  compound, 
blood  and  lacerated  brain  may  be  forced  out  of  the  Avound,  provided 
there  be  tearing  of  the  dui'a. 

Subdural  hemorrhage  is  commonly  due  to  depressed  fracture,  as  I 
have  said — to  depressed  fracture  with  a  tearing  of  blood-vessels.     It  is 


FRACTURES   OF   THE   SKULL  029 

not  always  possible  to  distinguish  subdural  from  extradural  hemorrhage, 
for  the  symptoms  of  the  two  are  usually  identical.  Commonly,  how- 
ever, subdural  hemorrhage  is  associated  with  most  active  symptoms, 
with  early  coma  and  rapid  fall  in  the  temperature.  An  extremely 
important  diagnostic  measure  is  lumbar  puncture,  b}'  which  blood- 
stained cerebrospinal  fluid  is  drawn. 

Cerebral  hemorrhage  presents  symptoms  identical  with  those  of 
apoplexy,  and  the  treatment  of  the  two  conditions  is  the  same,  except 
that  it  is  permissible,  though  hazaixlous  in  the  case  of  cerebral  hemor- 
rhage from  trauma,  to  ligate  the  common  carotid  artery  on  the  side  af- 
fected. 

Compound  fracture  of  the  skull  sometimes  causes  the  iTipture  of  a 
venous  sinus,  and  occasionally  sinuses  have  been  w-oundecl  in  the  course 
of  an  operation.  Obviously,  the  symptoms  of  hemorrhage  from  such 
a  wounded  sinus  are  quite  similar  to  the  already  described  symptoms  of 
arterial  hemorrhage,  except  that  venous  hemorrhage  is  slow  and  is 
controlled  easily  by  pressure. 

Harvey  Cushing,  writing  in  1902,  1903,  and  1905,  demonstrated,  in 
papers  of  remarkable  interest,  the  possibility,  if  not  the  vital  importance, 
of  operating  for  the  intracranial  hemorrhage  of  the  neic-born } 

All  physicians  know  the  sad  results  of  these  hemorrhages  in  babies 
— results  which  have  been  grouped  under  the  common  term  "  birth 
palsy."  These  infants  do  not  always  die  at  once — indeed,  they  may  live 
to  grow  up  and  attain  to  old  age  even.  The  immediate  effects  of  these 
birth  hemorrhages  are  seen  in  convidsions,  followed  by  paralyses  of  one 
or  both  sides;  by  loss  of  vigor;  by  gastro-intestinal  disturbances,  stupor, 
coma,  and  death.  Or  if  the  hemorrhage  be  sHght  and  confined  to  one 
side  only,  there  may  result  corresponding  paralyses  of  the  leg,  the  arm, 
and  the  face,  and  the  patient  will  survive  to  reach  maturity  in  this 
crippled  condition.  Some  of  the  victims  become  epileptics.  Some  are 
idiots.  Cushing  vigorously  maintains  the  thesis  that  many  of  these 
infants  may  be  saved  with  functions  unimpaired;  and  his  experience  in  a 
number  of  cases  bears  out  his  contention. 

The  hemorrhage  is  usually  venous,  and  is  due  to  rupture  of  some  of  the 
delicate  and  poorly  supported  venous  radicles  of  the  cerebral  cortex. 
The  cause  of  the  inipture  is  some  birth  violence— the  application  of 
forceps,  the  undue  overlapping  of  the  cranial  bones,  or  possibly  asphyxia 
of  the  baby.  Cortical  hemorrhage  is  a  common  cause  of  infant  mortal- 
ity in  those  babies  which  die  soon  after  birth,  for  the  collections  of 
blood  may  be  as  large  as  a  cerebral  hemisphere,  and  may  penetrate  into 
the  cerebellar  fossa  even. 

These  cases  are  grave,  urgent,  little  understood.  Many  of  them  can 
be  made  mild  and  simple,  and  should  be  recognized  at  once.  A  com- 
petent surgeon  should  be  called  to  open  the  skull  through  a  bone-flap, 
wash  out  the  clot,  restore  the  dura,  and  replace  the  severed  outer  parts. 

Contusions  of  the  brain  comprise  another  variety  of  injuries  asso- 

iThe  Mutter  Lecture  for  1901,  Amer.  Jour.  Med.  Sci.,  September,  1902;  ibid., 
June,  1903;  ibid.,  October,  1905. 


030  THE  HEAD   AXI)   srixE 

ciatcd  often  with  the  conclitions  we  have  (liscu.s.scd — fracture,  concussion, 
pressure,  heniojTliage.  Contusions  of  the  brain  are  conditions  al)out 
which  generations  of  surgeons  have  wrangled,  confounding  and  identi- 
fying contusion  with  concussion.  I  have  exphiined  how  such  eminent 
authorities  as  Keen  and  Kochei'  regard  concussion  as  a  mild  grade  of 
contusion.  In  this  writing  I  follow  the  teaching  of  von  Bergmann, 
who  limits  the  term  contusion  to  those  brain  injuries  which  aic  actually 
associated  with  gross  anatomic  damage  to  the  tissue.  V\v  distinguish 
also  between  contusions  and  vounds  of  the  brain.  A  blow  upon  the  skull 
which  damages  th(?  underlying  brain  without  exposing  it  to  the  outer 
air,  whether  the  skull  be  fractvired  or  not,  produces  a  contusion  of  the 
brain.  A  blow  upon  the  skull  which  damages  the  underlying  brain  di- 
rectly by  fracture  and  exposes  it  to  the  outer  air  results  in  a  wound  of  the 
brain.  Contused  brain  ma}^  vary  in  extent  from  a  trifling  point  to  an 
area  as  large  as  a  whole  cerebral  hemisphere.  Contused  brain  is  a  mass 
of  blood,  cerebrospinal  fluid,  and  disorganized,  crushed  brain  tissue. 
Contusions  of  the  brain  may  be  multiple  or  single,  while  the  results  and 
subsequent  course  of  the  contusion  vary  remarkably.  Since  there  is 
no  avenue  for  the  advent  of  infecting  organisms,  sepsis  does  not  follow 
contusions.  At  first  there  may  be  many  of  the  symptoms  characteristic 
of  concussion  and  pressure.  There  may  be  unconsciousness,  coma, 
vomiting,  slowing  of  the  pulse,  a  fall  of  the  temperature,  stertor,  parah'- 
ses,  choked  disk,  and  the  other  familiar  symptoms.  If  recovery  ensues, 
the  symptoms  may  disappear  wholly  or  in  part,  but  usually  certain 
stigmata  remain  or  develop,  such  as  blindness,  paralyses,  epilepsy,  or 
insanit}' ;  and  these  stigmata  are  due  to  the  curious  partial  or  ineffective 
healing  of  the  damaged  brain,  which  goes  through  a  routine  of  recon- 
structive changes:  blood  and  brain  tissue  are  dissolved  and  absorbed, 
so  that  at  the  site  of  the  contusion  there  results  a  cleft  or  cavity  which 
becomes  filled  gradually  and  transformed  into  a  scar,  w^hile  sometimes  a 
so-called  cyst  persists.  Certain  it  is  that  extensive  traumatic  defects  of 
the  brain  are  not  closed  by  a  regeneration  of  brain  tissue.  Moreover, 
one  sees  occasionally  cases  in  which,  during  the  course  of  years,  a  degen- 
eration of  the  nervous  elements  takes  place,  proceeding  far  bej^ond  the 
limits  of  the  original  injury — yellow  softening.^ 

Such  in  brief  are  the  characteristics,  conditions,  and  results  of 
cerebral  contusion,  and  one  feels  often  that  immediate  death  would 
be  the  happiest  lot  for  the  unfortunate  patient. 

Wounds  of  the  brain  take  on  many  of  the  characteristics  of  con- 
tusions, but  in  the  case  of  a  wound,  sepsis  fi-equently  lends  additional 
gravity  to  the  disaster. 

Writers  commonly  divide  wounds  of  the  brain  into  three  classes — 
punctured,  contused,  and  lacerated.  Such  an  artificial  division  is  by 
no  means  always  obvious — especially  the  distinction  between  contused 
and  lacerated  wounds.  Nor  is  the  distinction  vital.  Suffice  it  for 
the  practitioner  to  recognize  a  penetrating  wound  of  the  skidl  with 
damage  to  brain  tissue  and  the  opening  of  an  avenue  for  sepsis.  The 
*  R.  U.  Kronlein,  in  von  Bergmann's  System  of  Surgerj-,  vol.  i. 


FRACTURES    OF   THE    SKULL 


631 


history  of  brain  injuries  abounds  in  curiosities  and  amenities.  Surgical 
writers  from  the  times  of  Pare  and  of  Larrey  to  the  most  modern  of 
the  Japanese  tell  numerous  stories  of  the  destruction  and  loss  of  brain 
tissue;  of  projectiles  traversing  the  brain,  and  of  foreign  substances 
lodged  in  the  brain,  without  subsequent  notable  results.  These  occur- 
rences are  in  striking  contrast  to  the  deaths  following  slight  blows  on 
the  head — deaths  due  to  the  tearing  of  vessels,  with  subsequent  hemor- 
rhage and  com})ression.  Punctured  wounds  of  the  brain  are  among 
the  most  curious  of  all  the  curiosities  in  our  records,  and  none  is  more 


Fig 


409. — The  Harvard  "  cro^v-bar  case,"  with  subsketch  showing  relative  size  of 
skull  and  crow-bar. 


interesting  than  the  famous  "crow-bar"  case  of  the  Harvard  Medical 
School— a  case  in  which  a  quarrj-man's  tamping  iron  entered  from 
below  the  anterior  fossa  of  his  skull,  passed  out  through  the  vertex, 
and  left  the  man  not  much  the  worse  for  his  surprising  adventure. 
Years  afterward  when  he  died  both  the  skull  and  tamping  iron  were 
recovered,  and  now  repose  together  in  the  Warren  Museum  at  Harvard. 
It  is  needless  in  this  place  to  rehearse  the  signs  and  symptoms 
associated  with  wounds  of  the  brain.  Those  signs  and  symptoms  are 
quite  similar  to  the  evidence  of  brain  injury  which  I  have  already 
described — though  one  must  constantly  bear  in  mind  the  dangers  of 


632 


THK    HKAI)    AND    SI'IXE 


sep^iis  in  the  case  of  ])iaiii  ^v()Ululs,  and  the  fre^juent  Lite  evidences 
of  sepsis.  There  are  three  forms  of  sei)sis,  to  be  studietl  further  and 
later.  Suffice  it  here  to  note  the  three:  meningitis,  cei'ebral  abscess, 
sinus  thrombosis;  and  to  observe  that,  of  the  thi-ee,  meningitis  develops 
early — in  from  thirty -six  to  forty-eight  hours  after  the  injury;  absc(\ss, 
early  or  late — as  early  as  the  fifth  or  sixth  day,  as  late  as  the  thiid  or 
fourth  year;  while  sinus  thrombosis  appears  usually  towai'd  the  end 
of  the  first  week. 


Fig.  410. — Harvard  "  crow-bar  case."     Note  wound  tliiough  aiitnior  fossa  on  left. 
Patient  lived  many  years  after  the  accident. 

In  speaking  of  concussion  and  compression  a  few  pages  back  I 
referred  to  the  favorite  old  examination  question^ — the  distinction 
between  concussion  and  compression.  We  are  now  ready  briefly  to 
sum  up  that  distinction : 


In  Concussion. 
!.  The  symptoms  appear  immediately  after 
tlie  accident. 
Unconsciousness  and  vomiting. 
No  localizing  symptoms. 

The  pulse  is  slow  without  increase  of  ten- 
sion. 
The  respiration  is  slow. 

The  temperature  changes  little. 

I   Tiie    ])upils    may    Ite    dilated    or    con- 
tracted. 

Lumbar  puncture  draws  a  negative  fluid. 


In  Compression. 
The  symptoms  are  usually  delayed,  and 

appear  after  a  free  inter^•al. 
Restlessness,  stupor  merging  into  coma. 
Convulsions    or    paralyses    indicating 

local  cereiiral  damage. 
The  j)ulse  is  slow  and  of  high  tension. 

The  res])iration  may  he  stertorous  or  of 
the  Clu'yne-Stokes  type. 

The  tem))erature  falls  at  first  and  then 
rises. 

The  pupils  are  usually  unequal — di- 
lated on  the  side  of  injmy  and 
with  a  choked  disk. 

Lumbar  })uncture  frequently  draws  a 
bloody  fluid. 


FRACTURES   OF   THE   SKULL  633 

The  reader  will  assume  that,  as  a  rule,  a  concussion  is  an  affair  less 
serious  than  is  the  condition  of  compression,  ])ut  the  outcome  of  the 
cases  does  not  always  follow  this  assumption.  Severe  cases  of  con- 
cussion may  end  in  sudden  death,  while  cases  of  compression  may  be 
relieyed  spontaneously  or  by  a  surgical  operation,  and  the  patient 
may  recover  perfect  health. 

We  have  now  considered  in  somewhat  brief  fashion  certain  fractures 
of  the  skull,  with  their  complications  and  results — concussion,  hemor- 
rhage, compression,  and  contusions  and  wounds  of  the  brain.  These 
complications  and  results  are  commonly  associated  with  all  the  various 
forms  of  skull  fracture.  Before  continuing  this  discussion  further, 
we  should  examine  in  somewhat  greater  detail  the  subject  of  fracture 
of  the  base. 

Fracture  of  the  Base. — All  experienced  persons  are  familiar  with 
the  fact  that  basal  fractures  are  more  serious  than  vault  fractures.  A 
few  years  ago  students  were  taught  that  nearly  all  basal  fractures  are 
fatal,  so  that  when  the  diagnosis  of  basal  fracture  was  followed  by  recov- 
ery of  the  patient,  the  latter  fact  was  regarded  as  good  presumptive  evi- 
dence that  the  base  had  not  been  fractured.  We  know  now,  however, 
that  fracture  of  the  base  is  followed  by  recoveiy  in  a  great  many  cases, 
though  it  is  still  ipso  facto  a  more  grave  injury  than  vault  fracture. 

Why  is  basal  fracture  so  serious?  At  the  base  are  grouped  the  more 
important  vital  centers;  an  overw^helmingly  large  proportion  of  basal 
fractures  are  compound  fractures;  operations  for  the  relief  of  basal 
damage  are  difficult  or  are  ineffective. 

The  extent  of  a  basal  fracture  can  never  be  determined  accurately. 
All  three  fossae  may  be  involved,  or  two  or  one.  We  often  find  at  post- 
mortem a  fracture  of  the  posterior  fossa  which  had  been  overlooked 
entirely,  for  fractures  of  the  posterior  fossa  often  give  no  definite  charac- 
teristic symptoms. 

Moreover,  there  are  dangers  peculiar  to  each  fossa:  fracture  of  the 
anterior  fossa  promotes  septic  meningitis  through  infection  from  the 
nose  and  ethmoid  cells.  In  fracture  of  the  middle  fossa  infection 
advances  from  the  nasopharj-nx  and  from  the  ear.  Furthermore, 
injury  to  the  middle  fossa  may  involve  the  middle  meningeal  artery 
or  the  internal  carotid;  injury  to  the  posterior  fossa  is  seldoni  com- 
plicated by  sepsis,  but  may  result  in  extensive  tearing  of  venous  sinuses, 
with  a  consequent  hemorrhage  and  pressure.  One  sees  that  fractures 
of  the  middle  fossa  appear  at  first  as  the  most  dangerous,  though  severe 
injuries  to  the  brain  are  possible  in  fractures  of  all  fossae;^  yet  since 
the  more  important  brain  centers  He  in  the  posterior  fossa,  it  is  probably 
fair  to  estimate  that  the  gravity  of  the  prognosis  in  basal  fractures 
increases  in  accordance  with  the  position  of  the  fracture  from  before 
backward. 

In  general  terms,  the  mortality  of  fractures  of  the  base  is  about 
65  per  cent.,  while  the  mortality  of  fractures  of  the  vault  is  about  23 
per  cent. 

Before  entering  upon   a  further   consideration  of  head   lesions — 


034  THE    UKM)    AND    SPIXE 

sepsis,  tumor,  and  chronic  infections  especially — let  us  at  this  point 
sum  up  and  fornudate  the  symptoms  and  diagnosis. 

The  Symptoms  and  Diagnosis  of  Organic  Head  Lesions. —  ilie 
reader  should  recall  again  a  fact,  which  cannot  be  too  often  repeated, 
that  a  striking  and  notable  distinction  between  intracranial  lesions  and 
lesions  within  the  other  important  cavities  of  the  body,  lies  in  the  fact 
that  the  organs  within  the  skull  are  packed  into  a  firm,  immovable 
case,  the  organs  themselves  being  non-collapsible.  It  is  for  this  reason 
that  an  addition  to  the  cranial. contents" or  increase  of  the  intracranial 
tension  is  associated  with  the  most  alarming  and  fatal  results  even. 
One  of  the  most  common  and  most  significant  of  the  symptoms  of 
brain  damage  is  unconsciousness,  but  there  are  manifold  reasons  for 
unconsciousness,  so  that  it  is  worth  our  while  in  a  brief  paragraph  to 
consider  the  causes. 

The  Causes  of  Conm. — Coma  is  due  to — (1)  Brain  injury;  (2) 
apoplexy;  (3)  uremia;  (4)  epilepsy;  (5)  hysteria;  (6)  diabetes;  (7) 
opium  poisoning;  (8)  intoxication  from  alcohol,  ether,  and  other  anes- 
thetic drugs.  It  is  by  no  means  always  easy  to  determine  the  cause  of 
unconsciousness  if  the  surgeon  is  unfamiliar  with  his  patient's  previous 
condition.  In  police  station  and  hospital  practice  especiall}'  puzzling 
cases  arise,  which  often  contain  all  the  elements  necessary  for  mortify- 
ing errors  and  for  tragedy.  When  the  attendant  surgeon  makes  his 
examination,  he  should  look  with  pains  for  evidences  of  injur}-, — 
damage  to  the  scalp,  the  vault,  and  the  base, — especially  should  he  note 
bleeding  from  the  ears  or  nose.  But  an  epileptic,  a  (h-unkard,  or  a 
diabetic  may  fall  unconscious  and  receive  serious  head  injuries,  and 
in  such  cases  arise  the  puzzling  problems.  Search  the  patient  for  opium 
that  he  may  be  carrying;  and  note  the  odor  of  alcohol  or  opium  on  his 
breath.  The  victim  of  diabetes  may  smell  of  acetone  (violets).  Ex- 
amine the  urine  drawn  by  a  catheter  and  observe  in  it  the  specific 
gravity,  albumin,  acetone,  or  sugar.  Examine  the  fundus  of  the  eye  for 
choked  disk.  A  lumbar  puncture  may  draw-  the  bloody  fluid  due  to 
subdural  hemorrhage.  Hysteric  coma  is  most  common  in  boys  and 
young  women,  and  the  patient  can  swallow,  though  he  cannot  be  roused. 
In  postepileptic  coma  the  state  is  one  closely  resembling  sleep,  and  the 
patient  can  be  aroused.  In  uremic  coma  one  observes  frequently 
localized  edema,  and  there  may  be  convulsions.  In  apoplexy  there 
is  often  a  subnormal  temperature,  and  there  may  have  been  a  single 
convulsion.  In  opium-poisoning  look  for  the  familiar  pin-point  pupil 
and  a  slow  respiration,  down  to  three  or  four  a  minute,  i-emembering, 
at  the  same  time,  that  hemorrhage  into  the  pons  will  cause  pin-point 
pupil,  but  paralysis  as  well,  and  a  high  temperature  with  sweating. 
Thus  one  sees  that  the  problem  which  appeared  so  confusing  at  first 
may  readily  be  resolved  into  elements  more  easy  of  explanation. 

Cerebral  localization,  next  after  questions  relating  to  coma, 
furnishes  us  with  information  of  great  importance  when  we  come  to 
deal  with  the  diagnosis  of  intracranial  lesions,  yet  cerebral  localization 
is  a  matter  much  misunderstood  and  much  abused.     Cerebral  localiza- 


FRACTURES    OF   TIIF    SKIM.  035 

tion,  first  satisfactoiily  demonstrated  by  Fritsch  and  Hitzig,  is  that 
science  which  shows  tiie  rehition  of  certain  brain  centers  to  special 
functions,  voluntary  acts  and  impressions,  from  which  we  deduce  the 
conclusion  that  damage  to,  or  destruction  of,  given  brain  centers  will 
allect  proportionately  sensation  and  action.  If  this  were  all  there  is 
to  it,  cerebral  localization  would  be  a  simple  matter,  and  the  exact  site 
of  brain  lesions  always  could  be  determined,  but,  unfortunately,  in  the 
case  of  head  injuries  numerous  factors  complicate  the  problem;  there 
may  be  multiple  injuries;  there  may  be  damage  by  contrecoup;  there 
nuiy  be  secondary  hemorrhage  and  late  inflammation,  or  secondary 
destruction  of  brain  tissue.  Moreover,  the  immediate  symptoms  may 
seem  to  give  an  exaggerated  picture  of  the  damage,  while,  on  the  other 
hand,  extensive  laceration  of  the  brain  may  appear  to  be  accompanied 
by  slight  and  disproportionate  symptoms,  as  the  damage  may  have 
been  inflicted  upon  a  so-called  silent  area.  Some  years  ago  I  saw  in 
the  accident  room  of  the  Massachusetts  General  Hospital  a  young  man 
of  \'igorous  appearance,  who  seemed  perfectly  well  except  that  five 
hours  previously  he  had  been  rendered  totally  blind  by  a  gunshot 
wound  in  the  back  of  his  head.^ 

He  had  been  completely  conscious  since  the  accident;  there  were 
no  paralyses,  and  all  his  reflexes  were  normal;  the  pulse  was  not  slow. 
His  only  symptom  was  total  blindness.  The  reader  will  see  from  Fig. 
412  that  the  sight  center  of  the  brain  is  low  dowTi  in  the  posterior 
region  of  either  hemisphere.  This  patient  had  been  shot  with  a  32- 
caliber  rifle  through  the  right  side  of  the  occiput.  The  puzzling  question 
was,  why  should  he  be  blind  in  both  eyes — but  an  examination  of  the 
wound  quickly  solved  the  apparent  mystery.  The  bullet  had  entered 
the  right  side,  had  destroj-ed  the  right  visual  center,  and,  passing 
through  the  falx,  had  lodged  in  the  left  visual  center,  which  it  seemed 
to  have  destroyed  likewise.  An  extremely  interesting  surgical  fact  is 
that  a  bullet  fired  from  a  rifle  should  have  done  so  little  damage  after 
entering  the  brain.  I  enlarged  thoroughly  the  wound  in  the  bone, 
drained  both  hemispheres,  and  the  man  recovered  eventually,  with  a 
useful,  though  limited,  field  of  vision.  The  application  of  the  case  to 
our  text  lies  in  the  fact  that  a  gimshot  wound  in  so  vital  a  region  as 
the  occiput  was  shown,  by  the  objective  symptoms,  to  limit  its  damage 
to  a  surprisingly  small  area  of  brain. 

We  see,  therefore,  the  value  of  cerebral  localization  in  one  case,  so 
far  as  a  determination  of  the  limits  of  brain  damage  are  concerned. 
Not  many  years  ago  Chipault  published  a  great  and  exhaustive  treatise 
on  the  subject  of  craniocerebral  topography,  and  the  purpose  of  his  book 
was  to  enable  the  surgeon  to  cut  do"v\Ti  directly  through  the  outside  of 
the  head  upon  any  desired  area.  By  the  aid  of  careful  measurements 
from  such  fixed  points  as  the  external  auditory  canal  and  the  occipital 
protuberance  we  were  shovsTi  how  to  find  on  the  skull  a  point  corre- 
sponding to  that  area  of  the  brain,  let  us  say,  w^hich  controlled  the 

^  Henry  C.  Baldwin,  Gunshot  Wound  Involving  Both  Occipital  Lobes,  Boston 
Med.  and  Surg.  Jour.,  February  15,  1906. 


636 


FKACTIHE.S    OF   THE    SKULL 


63- 


movements  of  the  right  hand.  This  is  interesting,  but  less  important 
than  at  hrst  it  was  thought  to  be,  for  skulls  vary  so  nuich  that  rules 
cannot  be  made  to  apply  to  them  all.  Moreover,  in  these  days  we  are 
accustomed  to  explore  the  brain  through  large  windows  in  the  skull,  and 
to  reach  any  given  point  by  observing  its  relation  to  certain  fixed  and 
well-knoAvn  fissures  and  sulci  in  the  brain  itself.  The  student  should  be 
familiar,  however,  with  the  recognized  landmarks  described  by  Broca: 
The  pteriou  is  a  point  on  the  side  of  the  skull,  1\  inches  posterior 
to  the  external  angular  process,  on  a  level  with  the  roof  of  the  orbit. 
At  the  pterion  the  middle  meningeal  artery  is  found  passing  upward. 
The  inion  is  a  point  marked  by  the  external  occipital  protuberance. 


Fig.  414. — Diagram  showing  the  various  landmarks  utilized  as  points  of  measure- 
ment in  craniocerebral  topography.  Also,  in  red,  main  cerebral  fissures  and  lobes  of 
the  exposed  hemisphere  (.Cushing  in  Keen's  Surgery). 

The  glabella  is  the  midpoint  of  the  smooth  swelling  between  the  eye- 
brows. The  bregma,  placed  at  about  the  junction  of  the  sagittal  and 
coronal  sutures,  is  a  point  determined  b}'  the  intersection  of  two  lines 
—(1)  the  line  connecting  the  two  external  auditory  meatuses,  and  (2) 
the  line  connecting  the  inion  and  the  glabella. 


Figs.  411,  412,  and  413. — Diagrams  illustrating  the  more  definitely  locafized  of 
the  cortical  centers  of  the  exposed  part  of  the  hemisphere,  in  relation  to  the  main 
fissures  and  convolutions;  also  the  ''  word  centers''  isensors'  and  motor)  involved  in 
the  special  mechanism  for  speech.  (Receiving  sensor^'  stations  in  blue;  discharging 
motor  stations  in  red.)  Drawn  by  accurate  orthogonal  projection  of  actual  dissection. 
Note  that  centers  for  lower  extremity  are  practically  invisible  from  side,  and  that  the 
best  view  of  the  motor  field  is  obtained  from  above  (Cushing  in  Keen's  Surge rj-)- 


038  THK   HEAD    AND    SPINE 

To  find  the  fissure  of  Sylvius:  draw  a  line  from  the  external  angular 
process  to  the  occipital  protuberance.  The  fissure  of  Sylvius  begins 
on  this  line,  1^  inches  behind  the  angular  process,  the  main  branch 
running  toward  the  parietal  eminence,  the  ascending  branch  lying 
beneath  the  squamosphenoidal  suture. 

The  fissure  of  Rolando  is  the  center  of  a  most  impoi'tant  area,  and 
marks  the  posterior  limit  of  the  motor  region  of  the  brain.  It  begins 
near  the  median  line,  one-half  inch  posterior  to  the  middle  of  the  dis- 
tance between  the  inion  and  the  glabella.  The  fissure  runs  downward 
and  fonvard  at  an  angle  of  67.5  degrees  for  a  distance  of  3|  inches. 
Chiene's  method  for  finding  the  fissure  of  Rolando  is  as  follows:  take 
a  square  piece  of  paper  and  fold  it  into  a  triangle  (see  figure) ;  the  angle 
b  a  c  oi  the  triangle  is  45  degrees;  the  edge  d  a  is  folded  back  on  the 
dotted  line  a  e;  the  angle  d  ae  equals  half  of  45  degrees,  or  22.5  degrees, 
and  the  angle  r  a  e  also  equals  22.5  degrees.  Unfold  the  paper  in  the 
line  e  a;  in  the  figure  thus  formed  h  a  c  equals  45  degrees  and  eae  equals 
22.5  degrees;  e  a  b  equals  67.5  degrees,  which  is  the  angle  desired.  Place 
the  point  a  in  the  middle  line  of  the  head  over  the  point  of  origin  of  the 
fissure  of  Rolando;  the  side  a  b  is  laid  along  the  middle  line  of  the  head, 
when  the  line  a  e  will  be  found  to  correspond  to  the  fissure  of  Rolando — 
all  of  which  is  somewhat  confusing,  not  very  interesting,  and  is  much 
simplified  by  using  Horsley's  cyrtometer,  or  applying  Kronlein's  cranio- 
cerebral topographic  lines.  Ingenious  as  all  this  is,  the  surgeon,  and 
especially  the  expert  neurologic  surgeon,  seldom  employs  these  measure- 
ments. Modern  operations,  with  their  large  plastic  openings,  disclose 
such  extensive  fields  of  the  brain  that  accurate  external  measurements 
are  no  longer  needed  in  order  that  one  may  strike  upon  special  areas. 

Let  us  return,  therefore,  to  a  short  consideration  of  cerebral  localiza- 
tion. I  shall  take  many  of  the  statements  from  Harvey  Cushing's 
admirable  essay. ^  We  now  know,  through  the  accurate  methods  of 
cortical  stimulation  introduced  by  Sherrington  and  Griinbaum  (1901), 
that  that  portion  of  the  cortex  which  is  directly  excitable  by  a  unipolar 
electrode  consists  of  a  narrow  strip  which  lies  anterior  to  the  central 
fissure  (Rolando),  and  extends  to  the  depth  of  this  fissure  07i  its  anterior 
surface  alone.  This  is  the  true  motor  cortex.  The  central  fissure  divides 
the  cortex  into  an  anterior  motor  and  a  'posterior  sensory  field. 

The  excitomotor  cortex  is  limited  to  a  narrow  strip  of  the  exposed 
part  of  the  central  anterior  gyrus,  but  extends  to  the  depth  of  the  central 
fissure.  Its  chief  portion,  therefore,  does  not  lie  on  the  visible  surface, 
so  that  a  lesion  which  involves  the  motor  cortex  may  be  far  ovit  of  sight. 
The  Rolandic  fissure  is  not  a  straight  line,  but  is  broken  by  two  or 
three  more  or  less  well-developed  angles  (genua).  Opposite  the  two 
upper  genua  the  motor  strip  is  narrow,  and  its  representative  movements 
not  complex — the  movements  of  the  neck  and  tiaink.  Thus  the  genua  are 
valuable  surgical  landmarks,  particularly  the  middle  and  inferior  genua, 
which  are  often  brought  into  view  in  an  operation.     Above  the  uppei* 

^  Harv^ey  Gushing,  Surgery  of  the  Head,  Keen's  System  of  Surgerj'-,  vol.  iii,  pp. 
17-276. 


FRACTURES    OF   THE   SKULL 


Fig.  415. — Sylvian  line  connects 
external  angular  process,  A,  with  point 
75  per  cent,  of  distance  A'  to  /.  Super- 
ior Eolandic  point,  R',  lies  |  inch  behind 
midnaso-iiiionic  point  (50  per  cent.)- 
Inferior  Rolandic  point,  R",  lies  at  junc- 
tion of  Sylvian  line  with  perpendicular 
to  Reid's  base-line,  R-B,  at  preauricular 
point.  Sylvian  point  lies  at  junction  of 
Sylvian  line  with  line  from  meatus  to  25 
per  cent,  of  naso-inionic  line  cCushing  in 
Keen's  Surgery). 


Fig.  417. — NO  =  Kocher's  equator- 
ial line,  nasion  to  inion.  XL  =  Poirier's 
Sylvian  line  from  nasion  to  lambda. 
MA  =  Kocher's  anterior  meridian 
drawn  60°  from  meridian  line  at  midsag- 
ittal  point;  lies  over  precentral  convolu- 
tion and  crosses  XL  at  Sylvian  point, 
Sfs  =  superior  frontal  sulcus  at  one- 
third  of  MA;  Sfi  =  inferior  frontal  sul- 
cus at  two-thirds  of  MA.  MP  = 
Kocher's  posterior  meridian,  also  60° 
from  midline.  Lines  crossing  at  Sts  = 
superior  temporal  sulcus  (Gushing  in 
Keen's  Surgery). 


Fig.  416. — Forty-five  per  cent,  of 
median  naso-inionic  line  =  prero- 
landic  point;  55  per  cent.  =  Rolandic 
point;  70  per  cent.  =  Sylvian  line;  80 
per  cent.  =  lambda;  95  per  cent,  gives 
lower  edge  ,  of  occipital  lobe.  Line 
from  A,  external  angular  process,  to 
70  per  cent,  gives  Sylvian  fissure.  S 
a=  Sylvian  point  =  junction  of  second 
and  third  tenths  of  this  line,  while  R" 
=  inferior  Rolandic  point  =  junction 
of  its  third  and  fourth  tenths  (Cushing 
in  Keen's  Surgery). 


Fio-.  418. — GB  =  German  "  base- 
line "  from  inferior  edge  of  orbit  through 
upper  edge  of  meatus.  XJB  =  upper 
horizontal,  parallel  to  GB  through  up- 
per border  of  orbit.  M,  C  and  Z  =  per- 
pendicular at  posterior  border  of  mas- 
toid, at  condyle  and  midzygcma.  The 
Rolandic  line  unites  the  points  of  cross- 
ing of  the  posterior  perpendicular  and 
sagittal  lines,  R',  and  the  upper  hori- 
zontal and  anterior  perpendicular,  S. 
The  Svlvian  line  bisects  the  angle  R' 
SH.  Inferior  Rolandic  point,  R"  (Cush- 
ing in  Keen's  Svirgery). 


(340  THE    HEAD    AND    SPIXE 

genu  there  is  a  small  triangle  only  of  motor  cortex  which  can  be  exposed. 
When  stimulated,  this  ti-ianf;le  shows  movements  in  the  hip,  the  knee, 
and  toes.  Opposite  to  this  upper  genu  lie  centers  for  movements  of  the 
thorax  and  abdomen.  Between  it  and  the  middle  genu  lie  centers  for 
the  upper  extremity,  the  shoulder  being  represented  by  a  center  higher 
than  that  of  the  fingei's  and  thimib.  Opposite  the  middle  genu  aie  the 
centers  for  the  neck,  and  below  it  those  for  the  face — eyelids  above  and 
lips  below,  etc.  The  centers  for  the  jaws,  tongue,  vocal  cords,  pharynx, 
etc.,  are  lower  still,  usually  below  an  inferior  genu. 

If  the  above-named  cerebral  centers  be  damaged,  there  results  a 
corresponding  loss  of  motion,  but  sensation  is  not  impairetl. 

We  observe  also  that  certain  complex  movements  may  be  obtained 
by  stimulating  areas  adjoining  the  true  motor  cortex.  For  example, 
one  may  obtain  movements  of  sucking,  chewing,  sneezing,  and  speaking 
by  stimulating  the  pars  opercularis  below  the  central  anterior  gyrus 
(this  is,  near  Broca's  vocal  speech  center). 

The  pathway  downward  from  the  motor  cortex  is  by  the  p3'ramidal 
tract,  whose  fibers  degenerate  throughout  their  length,  if  their  cortical 
cells  be  injured. 

The  sensory  field  lies  behind  the  fissure  of  Eolando,  and  the  re- 
searches of  Campbell  in  particidar  seem  to  show  that  primary  registra- 
tion of  "common  sensation"  occurs  in  the  central  posterior  gyms. 
This  sensory  area  in  its  relation  to  the  fissure  of  Rolando  occupies  much 
the  same  position  posteriorly  that  the  motor  area  holds  anteriorly.  As 
Gushing  points  out,  the  sensory  field  is  largely  hidden  from  view  on  the 
posterior  surface  of  the  fissure,  and  does  not  extend  back  over  more  than 
the  anterior  half  of  the  exposed  gyrus.  The  fibers  to  this  sensory  field 
pass  from  the  thalamus  in  the  "  cortical  lemniscus  "  of  the  corona  radiata. 
These  fibers,  in  their  course,  lie  in  the  rear  part  of  the  internal  capsule. 
In  the  post-rolandic  region  there  are  registered  the  tactile  sense,  the 
muscular  sense,  and  the  sense  for  discriminating  points  in  contact.  As 
one  goes  further  back  on  the  cortex,  sensations  become  more  complex, 
so  that  deeper  and  more  extensive  lesions  are  needed  to  interpret  their 
transmission.  The  senses  of  pain  and  of  temperature  lie  probably  in 
the  intermediate  postcentral  zone  of  Campbell,  and  that  for  the  recog- 
nition of  objects — the  stereognostic  sense  in  particular — is  located  as  far 
back  as  the  parietal  lobe.  Visual  impressions  are  received  on  the  mesial 
surface  of  the  occipital  lobe,  in  the  calcarine  region. 

Auditory  impulses  are  received  apparently'  in  the  superior  temporal 
gyrus,  and  are  converted  into  conscious  perceptions  in  adjoining  parts  of 
the  temporal  lobe.  The  center  for  the  sense  of  smell  is  pi'obably  in  the 
pyriform  lobe,  while  the  center  for  taste  is  not  well  determined,  but  lies 
presumably  at  the  lip  of  the  limbic  lobe,  in  the  neighborhood  of  the 
incus. 

There  appear  to  he  four  corticcd  areas  concerned  in  speech  in  right- 
handed  people.  The  center  for  the  recognition  of  spoken  words  lies  in 
the  outskirts  of  the  primary  center  for  hearing,  in  the  superior  temporal 
gyrus  of  the  left  tempoi-al  lobe.     The  centers  for  vocal  speech  are  taught 


FRACTURES   OF  THE   SKULL  641 

by  Broca  to  lie  in  the  posterior  end  of  the  inferior  frontal  gyrus.  The 
visual  word  cent(T  eni])loyed  in  reading  is  in  the  angular  gyrus,  and  the 
writing  center,  if  such  exists,  is  in  the  posterior  end  of  the  middle  frontal 
gyrus. 

So  far  as  neurologic  studies  have  gone,  the  foregoing  description 
sums  up  briefly  our  present  knowledge.  Other  areas  of  the  cortex  appear 
to  be  concerned  with  complex  processes  of  association.  Lesions  of 
these  areas  are  largely  "  silent,"  so  far  as  our  present  methods  of  exami- 
nation show  us. 

We  have  already  considered  in  some  detail  the  symptom  coma. 
Let  us  now  continue  a  consideration  of  the  symptomatology  of  or- 
ganic lesions. 

Headache  is  one  of  the  cardinal  symptoms  of  head  lesions.  It  is 
common  enough  in  other  connections,  but  bear  in  mind  that  the  one 
symptom,  persistent  headache,  long  continued,  should  make  the  surgeon 
extremely  suspicious  of  intracranial  disease.  Headache  is  constantly 
present  in  diseases  of  the  meninges,  particularly  when  the  dura  is  in- 
volved; and  the  dura  takes  its  nerve-supply  almost  entirely  from  the 
trifacial.  Far  the  more  important  headaches,  how^ever,  are  those  due  to 
intracranial  pressure — to  tumor,  edema,  internal  hydrocephalus,  serous 
meningitis.  Those  headaches  due  to  pressure  have  no  relation  to  the 
seat  of  the  lesion,  as  a  rule.  Headaches  due  to  pressure  are  of  all  grades, 
from  a  dull  sense  of  pressure  to  agonizing  pain. 

Yomiting  is  the  next  cardinal  symptom  of  importance.  It  occurs  in 
the  presence  of  all  sorts  of  cerebral  lesions,  and  may  be  an  early  symptom 
of  concussion  or  contusion*.  We  must  recognize  especially  the  sudden 
projectile  vomiting  which  is  a  common  symptom  of  increased  intra- 
cranial tension,  due  to  brain  tumor,  to  the  edema  of  nephritis,  etc. 

Choked  disk  ("  optic  neuritis")  is  one  of  the  most  important  signs  of 
intracranial  pressure.  The  surgeon  should  look  for  it  in  all  cases  of 
head  injury  or  suspected  intracranial  disease.  As  Gushing  says,  "  it  is 
not  sufficient  for  the  examiner  to  be  able  to  recognize  a  choked  disk 
when  it  is  fuU  blown,  but  the  slight  edema  of  retina  and  nerve  head, 
with  early  distention  and  tortuosity  of  the  veins  which  precedes  actual 
'  choking. '  "  Gushing  asserts  further,  after  an  interesting  discussion 
of  the  nature  of  choked  disk,  that  the  rapid  subsidence  of  that  condition 
after  decompression  operations  leads  him.  to  believe  that  almost  all, 
if  not  all,  cases  of  choked  disk  are  primarily  of  mechanical  origin,  and  are 
not  a  true  neuritis. 

Besides  the  general  symptoms  of  organic  head  lesions  there  are 
numerous  so-called  focal  or  localizing  symptoms,  which  are  often  of  ex- 
treme interest.  There  are  disturbances  of  motion,  of  common  sensation, 
and  of  the  faculties  of  special  sense — irritative  symptoms. 

Motor  paralysis  is  always  the  most  striking  and  obvious  of  these 
focal  symptoms.  It  indicates  the  side  of  the  brain  which  is  involved. 
Sometimes  it  suggests  the  exact  situation  of  the  lesion.  It  may  be 
hemiplegic,  and  involve  an  entire  half  of  the  body,  or  may  involve  the 
trunk  and  extremities  only.     It  may  be  monoplegic  and  involve  but  one 

41 


642  THE   HEAD   AND   SPINE 

extremity.  It  may  be  paraplegic  and  affec-t  the  legs  chiefly,  or  diplegic 
and  impair  the  use  of  both  arms  and  legs. 

Muscular  spasticity  with  increased  reflexes  indicates  a  lesion  of  the 
intracranial  portion  of  the  motor  pathway.  Fui-therniore,  such  motor 
irritation  is  shown  often  by  epileptiform  convulsions.  The  process 
leading  to  convulsions  may  be  quiescent — the  cortical  cicatrix  of  an  old 
healed  focus  of  hemorrhage;  or  the  process  may  be  progressive— a  cyst 
or  tumor. 

Disturbances  of  sensation  also  may  result  from  coi-tical  and  subcorti- 
cal lesions.  They  may  be  irritative  and  associated  with  paresthesia,  or 
paralytic  and  accompanied  by  anesthesia.  A  certain  degree  of  motor 
impairment   almost    always    accompanies   these   sensory  disturbances. 

Such,  in  general  terms,  are  the  symptoms  which  should  suggest  to  the 
surgeon  some  localized  intracranial  lesion.  The  reader  interested  in 
this  matter  should  consult  the  larger  books  and  special  monographs, 
particularly  those  treatises  which  discuss  in  detail  regional  diagnosis — 
the  symptoms  resulting  from  damage  to  special  areas.  He  should  not 
be  misled,  however,  into  a  belief  that  with  our  present  knowledge  we  can 
always  determine  surely,  and  from  symptoms,  the  exact  location  of  an 
intracranial  lesion.  In  numerous  cases  we  can  so  determine,  however, 
and  in  most  cases  we  may  assert  positively  the  presence  of  some  disturb- 
ing element  within  the  skull,  though  we  may  not  state  its  location  or  its 
character. 

The  Meninges 

The  meninges  are  worthy  of  our  most  careful  study,  yet  must  we 
limit  ourselves  to  a  few  brief  paragraphs.*  One  recalls  certain  important 
anatomic  facts :  that  there  is  no  gross  communication  between  the  sub- 
dural and  subarachnoid  spaces;  that 
the  subdural  and  subarachnoid  spaces 
of  the  brain  can  be  injected  from  the 
corresponding  spinal  spaces;  that  the 
dura  carries  on  its  outer  surface  certain 
arteries  of  surgical  interest,  and  that  it 
incloses  the  great  venous  sinuses;  that 
the  dura  in  the  young  on  its  outer  sur- 

T--     ^-in     oi   ^  1     t  face  adheres  more  or  less  firmlv  to  the 

Fig.  419. — bketch  or  cross-sec-        ,     n  i      ,         •  •'     , 

tionof  longitudinal  sinus  in  itsmid-     skull,  and  that  it  acts  as  a  periosteum; 

course.     Note  width  of  parasin-     that  as   a  protection   for  the  brain  the 

Surge^r''''  ^^'"^^"'"'^  ''"  ^^^^""^^     dura,   owing  to   its  smooth  endothelial 

surface,  is  of  great  importance,  and  that 
rt  is  separable  into  two  layers,  between  which  are  inclosed  such  stmc- 
tures  as  the  Gasserian  ganglia.  The  dura  is  a  strong  membrane,  and 
such  of  its  prolongations  as  the  falx  and  the  tentorium  furnish  important 
supports  for  the  hemispheres.     The  longitudinal  sinus  and  other  sinuses 

1  For  a  delightful  discussion  of  meningitis,  brain  abscess,  and  brain  tumor  sec 
Charles  A.  Ballance's  published  lectures,  Some  Points  in  the  Surgerj'  of  the  Brain  and 
Its  Membranes,  1907. 


DEVELOPMENTAL  ANOMALIES  643 

lie  within  the  folds  of  the  dura,  and  into  the  longitudinal  sinus  or  its 
expansions  enter  many  of  the  more  important  superficial  cerebral  veins. 
In  its  mickllc  course  the  longitudinal  sinus  expands  broadly  (iacuncB  lat- 
eralea),  and  into  these  expansions  project  most  of  the  so-called  Pacchion- 
ian granulations,  whose  function  is  uncertain.  They  are  tuft-like  proc- 
esses from  the  arachnoid  and  contain  cerebrospinal  fluid.  The  middle 
meningeal  artery  furnishes  the  chief  blood-supply  to  the  dura;  and  its 
nerve-supply  is  abundant,  coming  mainly  from  the  trifacial.  Gushing 
believes  that  headaches  are  due  to  the  stretching  of  the  dura  or  of  its 
expansions. 

The  'pia  is  a  delicate  vascular  membrane  which  clings  closely  to  the 
convoluted  surface  of  the  brain  and  dips  into  all  its  irregularities.  The 
arachnoid,  on  the  other  hand,  lying  over  the  pia,  bridges  most  of  the 
irreg-ularities.  Remember  that  the  subarachnoid  spaces  thus  formed 
are  not  free,  but  are  honeycombed  by  strands  of  delicate  tissue  which 
bind  loosely  together  the  pia  and  the  arachnoid,  while  the  subdural 
spaces,  in  contrast,  are  open  and  free  for  the  circulation  of  fluid. 

The  ependyma  is  the  lining  membrane  of  the  ventricular  cavities — a 
layer  of  epithelial  cells,  mostly  underlain  by  a  thin  layer  of  neuroglia. 
The  cerebrospinal  fluid  is  probably  formed  through  the  action  of  the 
ependyma.  This  fluid  is  not  merely  a  lubricant  or  a  water  bed ;  it  should 
be  regarded  as  the  lymph  of  the  brain,  though  it  is  a  true  secretion  and 
not  an  exudation.  It  passes  from  the  meningeal  spaces  into  the  venous 
circulation  by  means  of  the  Pacchionian  granulations,  so  that  its  chief 
location  of  exit  is  into  the  venous  sinuses, 

DEVELOPMENTAL  ANOMALIES 

There  are  sundry  developmental  anomalies  due  to  failure  of  closure 
of  the  cranium,  and  into  these  unclosed  spaces  portions  of  the  cranial 
contents  protrude — cephalocele.  This  protrusion  is  usually  in  the 
middle  line  of  the  head,  and  is  most  common  in  the  occipital  region, 
though  it  may  protrude  from  the  anterior  fontanel.  According  to 
their  structure  and  contents  we  classify  cephaloceles  as  meningocele, 
membrane  containing  fluid;  encephalocele,  a  tumor  containing  mem- 
brane plus  brain,  and  encephaiocystocele,  a  tumor  containing  mem- 
brane and  brain  which  is  itself  distended  with  fluid  communicating  with 
a  ventricle.  True  meningoceles  and  encephaloceles  are  extremely 
rare.  Encephalocystoceles  are  not  uncommon.  In  making  the  diag- 
nosis one  distinguishes  the  last  readily  from  acquired  hernia  cerebri, 
though  they  may  be  mistaken  for  some  of  the  rarer  tumors.  An  infant 
the  victim  of  cephalocele  rarely  lives  long,  and  even  if  years  are  added, 
the  life  is  of  little  value. 

The  only  serviceable  treatment  is  by  operation.  Frequent  tappings 
avail  little  or  nothing.  A  meningocele  with  a  small  pedicle  may  be 
removed  successfully,  after  which  the  skull  defect  should  be  closed  by  a 
plastic  operation  with  bone  or  periosteum. 


644 


THE   HEAD    AND   SPINE 


HYDROCEPHALUS 

Hydrocephalus  is  a  sign  of  disease,  not  a  disease  in  itself.  We  speak 
of  hydrocephalus  as  chronic  or  acute,  congenital  or  acquired,  external 
or  internal.  The  acquired  condition  is  brought  about  in  most  cases  by 
some  obstruction  to  the  ventricular  outlets,  with  a  consequent  damming 
back  of  cerebrospinal  fluid.  The  term,  external  hydrocephalus,  appears 
to  be  a  misnomer.  Acquired  internal  hydrocephalus  may  result  from 
tumor  pressure,  from  inflammation  of  the  meninges  and  ependj-ma,  or 
from  venous  stasis  in  the  velum  interpositum.  Such  hydrocephalus 
usually  causes  death  before  any  great  ventricular  distention  is  reached. 


if 


>.  V' 


/^ 

\ 

r 

^ 

^« 

9E 

^^P 

^^- 

-■'-'■ 

" ' 

Fig.  420. — Hydrocephalus  (Massachusetts  General  Hospital). 

The  treatment  of  such  conditions  is  most  unsatisfactory,  as  we 
should  expect.  Sometimes  ventricular  puncture  may  relieve;  rarely, 
lumbar  puncture  in  the  less  advanced  cases,  though  the  last  maneuver 
is  dangerous.  At  times,  relief  of  symptoms  has  followed  a  simple  de- 
compres.sive  operation  on  the  skull,  with  puncture  of  the  ventricle.' 

Internal  hydrocephalus  of  the  congenital,  progressive  type  is  most 
characteristic  in  appearance.  It  may  be  due  to  a  congenital  syphilis 
or  to  an  abnormal  increase  in  the  amount  of  fluid  secreted,  or  to  both 
causes.     It  often  accompanies  cephalocele  and  spina  bifida,  and  consists 

^  W.  W.  Keen  punctures  the  ventricle  at  a  point  corrc'sponding  with  the  pos- 
terior end  of  the  temporal  Une,  about  3  cm.  behind  and  an  equal  distance  above 
the  external  auditon,-  meatus.  Enter  the  needle  in  the  posterior  i)art  of  the  first 
temporal  convolution,  aiming  at  the  summit  of  the  opposite  pinna.  Fluid  will 
be  found  at  a  depth  of  5  cm. 


CEREBROSPINAL   RHINORRHEA  645 

of  an  enormous  distention  of  the  ventricles  of  the  brain,  with  a  corres- 
ponding thinning  of  the  cortex.  The  appearance  of  the  unfortunate 
infant  victims  is  striking,  "  the  large,  thin,  flaring,  cranial  leaflets  being 
perched  on  the  .small  facial  bones  like  the  petals  of  a  single  water-lily 
on  its  calyx"  (Cashing).  These  heads  may  reach  a  surprising  size. 
Three  liters  and  more  of  fluid  have  been  reported  as  removed.  The 
weight  may  be  so  great  that  the  child  cannot  raise  his  head  or  move  it 
even.  These  children  do  not  cry,  because  crying  increases  the  intra- 
cranial tension  and  causes  pain.  They  may  become  victims  early  of 
gastro-enteric  disturbances,  and  die.  They  may  survive  as  physical  and 
mental  wrecks.  They  have  been  known  feebly  to  reach  adult  years. 
Some  of  the  milder  cases  have  become  arrested,  however,  either  spon- 
taneously or  after  the  employment  of  simple  tapping. 

These  cases  of  hydrocephalus  must  be  differentiated  from  certain 
cases  of  rachitis.  In  rachitis  evidences  of  bony  changes  elsewhere  in 
the  skeleton  should  suflace  to  establish  the  diagnosis,  but  the  two  affec- 
tions may  coexist.  In  doubtful  cases  a  lumbar  puncture  may  deter- 
mine the  diagnosis. 

The  treatment  of  congenital  hydrocephalus  has  been  the  subject  of  no 
little  discussion.  Nothing  but  mechanical  means  will  avail,  and  various 
such  means  have  been  advocated  by  sundry  surgeons.  Occasional  tap- 
pings accomplish  little,  for  the  fluid  quickly  reaccumulates.  Perman- 
ent drainage  of  various  forms  has  been  tried,  either  from  the  ventricles 
directly  or  through  lumbar  puncture.  Gushing  has  had  a  considerable 
measure  of  success  by  his  method  of  lumbar  drainage,  which  is  ex- 
tremely ingenious.^  He  determines  first  the  fact  that  ventricular 
fluid  will  flow  freely  from  the  lumbar  regions.  Then  he  opens  the  ab- 
domen, trephines  the  body  of  the  fifth  lumbar  vertebra  from  the  front, 
and  inserts  a  permanent  silver  cannula,  which  shall  drain  the  cerebro- 
spinal fluid  fon\'ard  into  the  peritoneal  cavity.  Ultimately,  through 
processes  of  healing,  the  fluid  is  turned  aside  into  the  retroperitoneal 
space  only,  whence  it  is  taken  up  by  the  radicles  of  the  receptaculum 
chyli,  as  experimental  observations  have  showTi.  This  operation,  of 
which  Gushing  reports  12  cases,  is  as  yet  too  recent  to  give  us  definite 
knowledge  of  ultimate  results.  The  method  is  applicable  to  selected 
cases  only — those  in  which  the  foramina  of  Magendie  and  Luschka  are 
open.  Such  is  the  status  at  the  present  writing  of  the  interesting  and 
obstinate  condition — internal  hydrocephalus. 

CEREBROSPINAL  RHINORRHEA 

A  curious  but  rare  discharge  of  cerebrospinal  fluid  from  the  nose 
has  received  the  appropriate  name  of  cerebrospinal  rhinorrhea.  This 
may  be  clue  to  an  injury,  to  a  chronic  hj^drocephalus,  or  may  occur 
spontaneously.  The  condition  is  serious  because  it  may  lead,  through 
the  open  nasal  channel,  to  an  infection  of  the  meninges  from  the  nasal 
passages.  The  discharge  may  be  abundant  or  occasional.  The  condi- 
^  Keen's  System  of  Surgerj^,  vol.  iii,  p.  123. 


646  THE   HEAD    AND   SPINE 

tion  may  prove  quickly  fatal  or  may  last  for  years;  and.  most  unfor- 
tunately, we  have  no  means  of  treating  it. 

Before  considering  inflanmiation  of  the  meninges  (meningitis), 
let  us  discuss  inllammations  of  the  meningeal  veins,  and  especially 
of  the  sinuses — inflammation,  which  leads  to  thrombosis. 

SINUS   THROMBOSIS 

Sinus  thrombosis  is  a  serious  malady.  Rarely  it  may  be  primary 
(marasmic)  and  pass  unrecognized  while  the  patient  lives.  This  form 
of  thrombosis  occurs  in  debilitated  persons,  especially  in  infants  and 
the  aged.  The  disease  may  spread  and  involve  numy  sinuses.  If 
thrombosis  occurs  in  the  straight  sinus,  it  will  set  up  most  profound 
intracranial  disturbances. 

Since  the  disease  occurs  commonly  at  the  end  of  long  illness,  the 
symptoms  are  not  marked,  and  such  as  they  are,  they  may  suggest 
brain  tumor.  Sinus  thrombosis  from  an  injury,  non-septic,  occurs 
rarely  also.  Gushing  records  two  notable  cases  of  non-septic  cavernous 
sinus  thrombosis,  one  of  which  occurred  after  an  operation  upon  the 
Gasserian  ganglion.  Thrombosis  of  this  sinus  results  in  an  exoph- 
thalmos with  extreme  swelling  and  ecchymosis  of  the  lids  and  con- 
junctivae. BUndness  is  almost  inevitable.  Extensive  non-septic  trau- 
matic thrombosis  is  associated  with  somewhat  sudden  symptoms — 
headache,  dehrium,  stupor,  perhaps  vomiting  and  convulsions,  and 
early  choked  disk. 

Infective  sinus  thrombosis  follows  most  commonly  some  form  of 
chronic  suppuration  elsewhere — especially  suppuration  in  the  sphenoid 
cavities,  the  antrum,  the  mastoid,  and  the  middle  ear.  Probabl}'  chronic 
otitis  media  is  the  cause  of  sinus  phlebitis  in  two-thirds  of  aU  cases  of 
such  phlebitis,  and  the  process  seems  to  be  more  frequent  on  the  right 
side.  The  sinuses  close  to  the  ear  become  involved  first  in  inflamma- 
tion resulting  in  thrombosis,  and  the  process  spreads,  extending  to  the 
lateral,  the  sigmoid,  and  the  sagittal  sinuses,  and  into  the  jugidar  vein 
in  the  neck  even,  or  the  petrosal  and  cavernous  sinuses  may  be  the 
first  vessels  affected. 

The  symptoms  of  septic  sinus  thrombosis  follow  upon  the  long- 
standing chronic  evidences  of  the  initial  disease  (in  ear,  antmm,  or 
elsewhere)  and  spread  rapidly.  There  are  chill,  headache,  nausea, 
dizziness,  and  vomiting.  The  temperature  nms  high,  with  remis- 
sions. The  pulse  is  rapid.  There  are  sweating  and  leukocytosis. 
The  thrombus  may  break  down,  and  septic  particles  may  be  carried 
into  the  general  circulation,  with  a  resulting  pyemia.  Abscesses  de- 
velop in  the  lungs.  The  patient's  mind  may  remain  clear  unless  menin- 
gitis or  cerebral  abscess  supervene. 

One  may  not  always  and  readily  make  a  diagnosis  of  thrombo- 
phlebitis in  the  sinuses.  Of  course,  the  diagnosis  may  be  easy  when 
the  source  of  the  infection — in  the  ear  or  elsewhere — is  discovered,  and 
when  there  are  present  such  obvious  symptoms  as  tenderness  along 


MENINGITIS  647 

the  jugular  vein;  pain,  tenderness,  and  edema  behind  the  mastoid; 
sudden  exophthalmos  and  chemosis;  paralysis  of  nerves,  and  the  like. 
But  these  symptoms  may  not  appear  until  late,  and  the  disease  may 
be  mistaken  earh'  for  some  general  systemic  infection.  If  the  infec- 
tion run  untreated,  meningeal  or  cerebral  complications  supervene, 
with  a  general  pyemia,  under  which  the  patient  sinks  gradually  and 
dies  usually  in  the  course  of  a  month  or  six  weeks. 

The  treatment  of  sinus  thrombosis  is  purely  operative,  and  the 
exact  point  of  attack  is  dependent  upon  the  source  of  origin  and  loca- 
tion of  the  infection.  We  endeavor  always,  therefore,  to  open  down 
upon  the  involved  sinus  and  to  clear  it  out.  For  example,  in  the  case 
of  sigmoid  phlebitis  the  surgeon  opens  the  mastoid  cells,  lays  bare  the 
sinus,  and  determines  its  contents  by  aspiration  with  a  hypodermic 
needle.  If  the  sinus  be  found  occluded,  the  clots  must  be  washed  out. 
If  the  jugular  vein  is  obviously  involved,  one  may  follow  the  brilliant 
method  advocated  by  Zanfel  in  1880;  tie  the  jugular  low  in  the  neck, 
and  wash  out  the  clots  in  the  vein  and  sinus  by  through-and-through 
irrigation.  By  such  measures  surgeons  have  been  able  to  record  a 
large  number  of  brilliant  and  successful  operations. 

MENINGITIS 

Meningitis  proper  is  divided  commonly  into  the  subjects  pachy- 
meningitis and  leptomeningitis,  the  former  indicating  inflammation  of 
the  dura;  the  latter,  inflammation  of  the  pia  arachnoid. 

When  we  consider  'pachymeningitis,  we  use  sundry  terms  to  indicate 
the  area  involved— pachymeningitis  externa,  pachj-meningitis  hsemor- 
rhagica  interna.  External  inflammation  of  the  dura  follows  septic 
infections  from  injuries,  middle-ear  disease,  and  other  local  sources,  and 
is  the  common  precursor  of  internal  inflammation  of  the  dura  and  of 
the  pia  arachnoid.  Internal  hemorrhagic  ^pachymeningitis  is  charac- 
terized by  an  easily  detached  membrane  with  numerous  new-formed 
blood-vessels  on  the  inner  surface  of  the  dura.  The  symptoms  vary 
and  ma}^  be  those  merety  of  progressive  dementia,  though  there  may 
coexist  often  severe  headaches  with  convulsions.  We  have  no  satisfac- 
tory treatment  for  this  hemorrhagic  form  (which  perhaps  should  not  be 
designated  meningitis  at  all),  though  certain  cases  seem  to  have  been 
greatly  relieved  by  decompressive  operations.  The  treatment  of  external 
meningitis  is  much  more  satisfactory  if  the  diagnosis  can  be  made. 
Open  the  skull  liberally  by  turning  back  a  large  bone-flap  in  the  neigh- 
borhood of  the  infected  area.  Irrigate  gently  with  hot  salt  solution 
the  meningeal  surface,  and  provide  suitable  rubber-tissue  drainage. 
One  may  thus  look  for  a  striking,  though  somewhat  protracted,  re- 
covery in  manj^  cases. 

Leptomeningitis  unfortunately  follows  dural  infections,  whether 
from  traumatic  tearing  of  the  dura  or  from  chronic  bone  suppurations. 
Moreover,  leptomeningitis  may  be  a  primaiy  and  specific  malady, 
which   becomes   generalized   early.     Secondary   forms,    on   the   other 


648 


THE    HEAD    AND    SI'IXE 


hand,  tend  to  remain  localized.  Leptomeningitis  may  be  rapidly  fatal 
in  a  few  hours,  therefore,  or  may  run  on  for  months.  A  specific  foim  has 
received  the  name  cerebrosi)inal  fever  ("  spotted  fever"),  and  is  due  to 
the  Diplococcus  intracellularis  (Weichselbaum),  the  ailment  being 
frequently  epidemic. 

It  is  needless  here  to  discuss  surgically  this  grave  disease  (cerebro- 
spinal fever)  beyond  pointing  out  the  fact  that  certain  operative  mea- 
sures, with  permanent  drainage,  offer  promise  of  benefit.  Lumbar 
puncture  with  the  evacuation  of  fluid  may  avail  if  the  basal  foramina 
are  open.  In  other  cases  the  suboccipital  drainage  through  trephining 
beneath  the  cerebellum,  a  method  suggested  by  Charles  A.  I^allance, 
seems  to  be  preferable.  A  further  and  still  more  promising  measure 
is  to  tap  the  ventricles  in  the  manner  I  have  already  described.  This 
subject  is  still  under  discussion,  however,  at  the  present  writing,  and 


Fig.  421. — Lumbar  puncture  (C'hipault):  A,  Method  of  Quincke;  B,  method  of 
Marfan;  C,  method  of  Chipault.  The  simplest  plan  seems  to  be  to  puncture  between 
the  fourth  and  fifth  lumbar  vertebrse.  The  space  between  these  vertebrip  corre- 
sponds to  the  highest  part  of  the  iliac  crests.  Chipault,  however,  maintains  that  tl  e 
lumbosacral  space  is  preferable,  since  it  is  the  largest,  is  surrounded  by  good  land- 
marks, and  is  opposite  the  terminal  enlargement  of  the  dural  sheath  (Ballance). 

I  refer  the  interested  student  to  the  larger  treatises  on  surgery.  Hap- 
pily, the  serum  treatment  of  Flexner  is  now^  supplanting  all  operative 
treatment. 

Suppurative  leptomeningitis  concerns  the  surgeon  especially,  and 
the  diagnosis  of  this  condition  is  not  always  obvious.  We  may  early 
confound  it  with  "  meningitis  serosa,"  an  extremely  interesting  condi- 
tion described  by  Quincke  in  LS93.  Meningitis  serosa  is  not  associated 
with  suppuration,  though  there  appears  an  abundant  serous  exudate, 
an  increase  in  cerebrospinal  fluid,  injection  of  the  meninges,  and  symp- 
toms of  intracranial  pressure,  which,  if  not  relieved,  may  lead  to  death. 
In  these  cases  lumbar  puncture  is  our  trump  card.  Lumbar  puncture 
alone  will  serve  to  establish  a  diagnosis,  and  if  the  withdrawn  fluid  be 
sterile,  drainage  frequently  will  result  in  a  cure  of  the  serous  meningitis.^ 

1  The  cuts  in  the  text  illustrate  admirably  satisfactory  methods  of  lumbar  punc- 
ture, Charles  A.  Ballance,  ibid. 


MENINGITIS  649 

In  suppurative  loptomoningitis  we  find  commonly  the  streptococcus, 
the  Staphylococcus  aureus,  alhus,  and  citreus,  and  sometimes  the  Bacil- 
lus pyogenes  foetidus  and  other  rarer  organisms. 

The  symptoms  of  purulent  forms  of  meningitis  present  a  picture 
which  is  sometimes  characteristic  and  sometimes  obscure.  Commonl}-, 
fever  begins  within  forty-eight  hours  of  the  infection,  and  rises  gradu- 
ally, running  up  to  104°,  105°,  106°  F.;  the  pulse  is  quick,  full,  and 
bounding,  and  there  are  superadded  the  other  familiar  signs  of  intra- 
cranial pressure — headache,  vomiting,  choked  disk,  paralyses,  and  vary- 
ing focal  symptoms. 

Operative  treatment  of  suppurative  leptomeningitis  may  cure, 
though  the  disease  is  still  justly  regarded  as  one  of  the  most  fatal 
known  to  us.  Nevertheless,  I  have  had  brilliant  recovery  follow  a 
liberal  exposure  and  drainage  of  the  meninges,  the  opening  of  the  skull 
being  made  to  depend,  so  far  as  possible,  upon  the  original  site  of  in- 


Fig.  422. — Sketch  showing  method  of  lumbar  puncture.  A  line  joining  the  highest 
part  of  the  iliac  crests  bisects  the  space  between  the  fourth  and  fifth  lumbar  vertebrse. 
This  is  the  best  guide  in  lumbar  puncture.  A  fine  hollow  needle,  7  cm.  long,  is  re- 
quired (Ballance). 

fection.  I  reported  in  1906  a  case  of  leptomeningitis  following  fractured 
middle  fossa,  with  a  gradually  resulting  delirium  associated  with  right- 
sided  paralyses  and  incoherence  of  speech.  I  opened  the  skull  and 
dura  over  the  left  Rolandic  area,  drained  the  field  for  some  days,  and 
was  rew^arded  by  the  complete  recovery  of  the  patient.  Irrigation  is 
not  to  be  commended.  Frequently  acute  internal  hydrocephalus  com- 
plicates meningitis,  when  one  must  resort  promptly  to  puncture  of  the 
ventricle. 

From  a  considerable  experience  of  my  own,  and  from  the  records  of 
other  surgeons,  I  am  convinced  that  the  time  has  gone  by  for  abandon- 
ing to  their  fate  patients  critically  ill  with  meningitis.  The  disease  is 
comparable  to  diffuse  peritonitis.  The  patients  wall  die  if  let  alone. 
Occasionally  they  recover  if  prompt  drainage  be  boldly  instituted,  sup- 
plemented by  the  exhibition  of  urotropin. 

The  ependyma  lining  the  cerebral  ventricles  is  subject  to  infection, 


050  THE    HKAD    AND    .SPIXI-: 

and  the  resulting  ependymitis  is  seemingly  a  specific  malady,  without 
any  known  association  with  meningitis.  Gushing  observes  that  these 
ependymal  inflammations  doubtless  play  a  large  part  in  hydrocephalus, 
and  have  received  less  attention  than  they  deserve.  The  inllamma- 
tions  result  in  a  sudden  closure  of  one  or  another  of  the  ventricular 
channels.  Immediately  symptoms  of  acute  hydrocephalus  supervene, 
with  the  familiar  signs  of  intracranial  pressure — headache,  vomiting, 
and  choked  disk. 

It  is  usually  impossible  to  attack  directly  the  source  of  trouble, 
but  almost  always  an  extensive  decompressive  operation  will  relieve 
the  symptoms.  Occasional  cure  may  result.  Sometimes  aspiration 
of  the  ventricle  at  the  same  time  will  be  advantageous. 

Tuberculous  and  syphilitic  meningitis  are  not  generally  regarded 
as  surgical  ailments,  and  their  discussion  here  may  not  be  appropriate, 
but  one  word  regarding  treatment  is  in  place :  The  mechanical  disturb- 
ances from  pressure  should  be  met  by  lumbar  puncture,  and  when 
hydrocephalus  is  present,  by  ventricular  puncture.  In  the  case  of 
syphilitic  meningitis  operative  treatment  should  be  preceded  by  a 
thorough  course  of  potassium  iodid,  but  this  should  not  be  persisted 
in  to  the  neglect  of  operation  for  more  than  three  weeks  if  there  be  no 
relief  from  the  symptoms.  Occasionally  gummata  may  be  attacked 
directly,  but  even  when  they  are  not  found,  decompression  frequently 
wall  relieve  the  symptoms. 

MENINGEAL   TUMORS 

Meningeal  tumors  occasionally  are  seen.  If  they  spring  from  the 
pia  arachnoid,  they  frecjuently  can  be  located  readily.  If  they  are  of 
dural  origin,  their  position  may  not  be  so  obvious.  These  latter 
tumors  are  often  of  the  most  malignant  sarcomatous  nature.  They 
attack  the  cranial  bones,  and  may  penetrate  them  and  appear  externally 
as  soft,  pulsating  swellings.  I  shall  consider  further  this  subject  in 
connection  with  cerebral  tumors. 

The  Cranium 

Diseases  of  the  cranium  belong  as  properly  with  meningeal  disease 
as  with  scalp  disease.  We  have  just  seen  that  certain  malignant  growths 
of  the  meninges  may  penetrate  the  skull  from  within.  There  are 
numerous  other  maladies  of  the  bones  which  the  writers  describe — 
atrophy,  hypertrophy,  acromegaly,  gigantism,  osteitis  deformans, 
osteomyelitis,  cranial  syphilis,  and  tuberculosis.  All  these  are  subjects 
which  I  pass  over  with  their  mention  merely,  and  with  the  suggestion 
that  they  are  not  often  amenable  to  surgical  treatment. 

TUMORS  OF  THE  CRANIAL  BONES 

Tumors  of  the  cranial  bones  merit  some  further  notice,  however. 
Osteomata  are  not  especially  uncommon.     They  are  benign  tumors. 


TUMORS   OF  THE   CRANIAL   BONES  651 

hiird  or  soft,  and  arise  either  from  the  periosteum  or  from  the  cartilage. 
"Exostosis"  is  the  term  commonly  applied  to  them.  They  may  be 
external  or  internal.  They  may  be  multiple  or  single,  and  they  vary 
in  size  from  minute  nodules  to  large,  irregular,  flat,  or  pedunculated 
masses.  When  on  the  inner  surface  of  the  skull,  they  may  reach  a  con- 
siderable size  without  producing  symptoms;  or  they  may  cause  notable 
symptoms  either  of  general  pressure  or  of  focal  disturbance.  They  may 
appear  in  the  accessory  sinuses  of  the  ethmoid  and  sphenoid,  fill  these 
cavities,  and  invade  the  neighboring  spaces — the  orbit,  the  nares,  or 
the  base  of  the  skull.  These  latter  osteomata  are  composed  of  a  shell 
covering  a  central  spongy  portion.  Generally  they  are  recognized 
easily,  but  sometimes  one  mistakes  them  for  sarcomata. 

If  osteomata  are  not  unsightly  and  do  not  cause  symptoms,  they 
may  be  let  alone;  but  if  they  are  troublesome,  the  surgeon  may  under- 
take their  removal.  The  removal  of  osteomata  is  not  always  easy 
and  may  be  extremely  dangerous,  for  the  whole  thickness  of  the  skull 
may  be  involved,  and  in  the  case  of  tumors  of  the  cranial  sinuses,  opera- 
tion may  be  followed  by  septic  infections.  Writers  have  recorded  a 
high  mortality.  The  surgeon  should  consider  carefully  the  question 
of  drainage,  and  should  certainly  employ  it  in  the  face  of  suppuration 
and  hemorrhage. 

Malignant  tumors  of  the  cranial  bones  occur  occasionally. 
Sarcomata  may  be  primary  there  or  secondary,  and  hypernephromata 
have  been  reported.  Sarcomata  and  hypernephromata  occur  at  all 
ages  and  in  both  sexes.  Primary  sarcomata  arise  from  the  diploe  or 
from  the  dura,  and  abundant  new  bone-formation  may  be  associated 
with  their  growth.  It  is  an  extremely  interesting  fact  that  their 
beginnings  often  seem  to  be  associated  v/ith  traumatism,  so  that  the 
surgeon  must  bear  in  mind  the  possibility  of  present  sarcoma  when 
dealing  with  old  head  injuries  followed  by  persistent  local  pain  and 
symptoms  of  intracranial  pressure.  Unfortunately,  early  diagnosis  of 
these  internal  malignant  growths  is  generally  impossible  except  through 
an  exploration  of  the  skull,  and  here  again  is  a  further  reason  for  operat- 
ing early  in  cases  of  obvious  and  pronounced  cranial  or  intracranial 
disturbance.  Bloodgood  has  shown  that,  with  the  exception  of  myelog- 
enous sarcomata,  operations  for  sarcoma,  even  on  the  extremities, 
are  futile.  The  same  observation  probably  would  hold  true  in  the 
case  of  the  skull.  Myelogenous  sarcomata,  however,  may  often  be 
cured  by  a  purely  local  operation— excision  or  curetting  even. 

Cancer  of  the  skull  is  always  a  metastatic  process,  except  in  those 
cases  in  which  the  skull  is  attacked  by  direct  extension  of  cancer  from 
the  scalp. 

Myeloma  (Kahler's  disease)  is  interesting,  though  little  under- 
stood. It  is  a  multiple  tumor-forming  disease  of  the  marrow,  associated 
with  absorption  of  bone,  pathologic  fracture,  and  grievous  deformities. 
As  yet  it  is  incurable  and  is  recognizable  by  the  presence,  in  the  urine, 
of  an  albuminous  body  named  from  its  discoverer,  Bence-Jones.  Mye- 
loma of  the  skull  is  merely  a  local  expression  of  a  general  disease. 


652  THE    HEAD    AND    SPINE 

The  Brain 

We  are  wont,  in  discussion,  to  distinguish  injuries  of  the  bniin  from 
diseases  of  the  brain,  and,  for  the  sake  of  convenience  perhaps,  such  a 
division  of  the  subject  is  permissible.  In  fact,  however,  one  cannot 
always  divide  injuries  from  diseases  in  any  arbitrary  fashion.  Nor 
can  we  group  brain  lesions  always  apart  from  lesion  of  the  brain's  en- 
velops and  bony  shell.  The  whole  subject  of  the  nomenclature  of  brain 
lesions  is  one  of  continually  increasing  difficulty  and  confusion  the  nioie 
we  attempt  to  Hmit  these  considerations  by  arbitrary  anatomic  terms. 
We  must  study  the  head  as  a  whole,  but  we  must  not  depart  so  far  from 
conventions  as  to  make  our  discourse  unintelligible.  Hitherto  in  this 
chapter  nominally  we  have  dealt  with  the  skull  and  the  meninges,  but 
inevitably  we  have  been  obliged  to  consider  the  topography  and  injuries 
of  the  brain,  and  we  have  constantly  been  bearing  in  mind  the  fact  that 
damage  to  the  skull  and  meninges  is  important  only,  and  so  far  as  it 
cripples  the  brain  itself.  Let  us  now  advance  more  deeply  into  the 
field  and  consider  diseases  peculiar  to  the  brain — inflammations  and 
tumors  and  the  remote  results  of  certain  brain  lesions. 

ENCEPHALITIS 

Acute  encephalitis  ^  may  exist,  though  it  is  not  common.  According 
to  Striimpell,  the  process  is  similar  to  the  acute  poliomyelitis  of  the 
cord;  the  symptoms  are  those  which  accompany  all  severe,  acute 
cerebrospinal  affections,  and  are  due  to  the  intracranial  tension — with 
headache,  stupor,  vomiting,  fever,  delirium,  rapid  pulse,  and,  in  the 
graver  cases,  choked  disk,  coma,  slow  pulse,  and  stertor.  There  may 
be  paralyses  or  epileptiform  seizures.  Children  are  the  victims  com- 
monly, and  they  may  recover  as  physical  and  mental  cripples. 

Treatment  hitherto  has  been  of  little  value,  though  Cushing  records 
his  opinion  that  an  extensive  decompression  operation  may  be  of  service. 

A  much  more  common  form  of  infection  of  the  brain  is  that  illus- 
trated by  cerebral  abscess. 

CEREBRAL  ABSCESS 

I  have  already  hinted  at  the  development  of  brain  abscess  as  the 
sequel  of  local  bone  disease — in  the  middle  ear,  the  mastoid,  the  frontal 
sinus,  etc.;  or  abscesses  may  follow  traumatic  injuries  to  the  head,  and 
rarely  some  general  infection,  such  as  is  set  up  by  a  suppurative  pneu- 
monia, by  influenza,  by  typhoid  fever,  or  by  tuberculosis.  Some  of  these 
abscesses  are  of  slow  development  and  long  duration.  Charles  A. 
Ballance  especially  dwells  upon  that  form  of  abscess  which  may  be 
likened  to  the  shirt-stud  felon.  In  such  a  case  the  infection  penetrates 
slowly  through  the  cerebral  cortex,  burrowing,  as  it  were,  and  leaving 
a  track  behind  it.     Deeper  in  the  brain,  in  the  white  substance,  the 

*  This  disease  appears  to  be  growing  increasingly  frequent  and  to  develop  in 
epidemics.  The  year  1909  saw  a  great  number  of  these  cases  in  both  America  and 
Europe. 


TUMORS   OF  THE    BRAIN"  653 

advancing  infection  spreads  out  rapidly  in  the  softer  tissues,  producing 
the  effect  of  a  mushroom-shaped  mass.  Ballance  reminds  us  also  that 
brain  abscess  or  sinus  infection  is  a  more  common  complication  of  chronic 
ear  disease  than  is  acute  meningitis,  whereas  meningitis  f]-ecjuently  has 
followed  unskilful  attempts  to  remove  a  foi^eign  body  from  the  ear. 
The  abscess  may  increase  rapidly  and  break  through  all  barriers  into 
the  ventricles,  or  outward  to  the  brain  surface,  or  it  may  i-un  a  chronic 
course  with  few  striking  symptoms.  A  chronic  abscess  is  encapsulated 
and  may  persist  for  months  or  years  even.  When  symptoms  of  brain 
abscess  appear,  they  are  due  to  three  factors — the  presence  of  pus ;  the 
increased  tension  within  the  skull;  the  interference  with  or  damage  to 
function;  so  that  we  shall  expect  fever,  chills,  and  vomiting;  headache; 
choked  disk ;  paralyses,  anesthesia,  convulsions,  and  loss  or  impairment 
of  the  special  senses.  One  should  attempt  to  disting-uish,  therefore, 
between  cerebral  abscess  and  such  other  inflammations  as  meningitis, 
ependymitis,  and  septic  sinus  thrombosis.  Such  differentiation  fre- 
quentty  is  impossible  until  actual  exploration  has  revealed  the  tiaie 
condition. 

Brain  abscess,  like  abscess  elsewhere,  must  be  treated  by  operation. 
We  must  evacuate  pus.  In  the  case  of  brain  abscess,  however,  unlike 
abscess  elsewhere  in  the  body,  we  find  ourselves  dealing  with  a  circum- 
scribed collection  of  fluid  which  lies  in  an  almost  fluid  medium.  As  pus 
flows  out  brain  flows  in,  so  that  complete  and  thorough  drainage  is  not 
easy.  Moreover,  our  operations  must  be  determined  often  by  the 
source  of  origin  of  the  abscess.  Local  bone  disease  must  be  investigated 
and  removed;  the  further  course  of  the  spreading  infection  must  be 
followed  into  the  brain — if  necessary,  after  a  considerable  removal  of 
the  bones  of  the  skull;  and  the  abscess,  wherever  found,  must  be 
thoroughly  evacuated.  As  Gushing  says:  "  Unfortunately,  these  opera- 
tions continue  to  be  conducted  as  a  last  resort  in  the  '  manifest '  or  even 
near  the  terminal'  stage  of  the  disease.  They  should,  on  the  other 
hand,  be  undertaken  early  without  waiting  for  unequivocal  symptoms." 

Surgeons  differ  in  their  views  regarding  methods  of  exploring  the 
brain  for  abscess  which  is  not  immediately  apparent — whether  to  explore 
with  a  trocar  or  with  a  narrow-bladed  knife.  I  am  inclined  to  accept 
the  dictum  of  Ballance,  who  advocates  the  use  of  the  knife.  After  the 
pus  is  found  and  evacuated,  we  must  institute  gauze  drainage,  and  the 
gauze  should  remain  long  in  position.  And  we  must  not  forget  that  there 
may  be  multiple  abscesses,  in  which  case  the  drainage  of  one  may  not  be 
followed  by  the  prompt  relief  of  symptoms  for  which  we  looked.  Then, 
again,  if  the  patient's  condition  permit,  there  is  no  resource  save  another 
operation.^ 

TUMORS  OF  THE  BRAIN 

Ballance,  in  his  splendid  lecture  on  brain  tumors,  remarks:  "It 
would  be  impossible,  in  the  course  of  a  single  hour,  to  give  any  adequate 

^  The  admirable  essays  of  Ballance  and  Gushing  should  be  read  by  the  surgeon 
who  is  planning  one  of  these  difficult  operations. 


654  THK    HEAD    AND    SI'INE 

account  of  so  vast  a  subject  as  that  of  intracranial  tumors."  Our 
statements  in  this  chapter  accordingly  must  be  of  the  briefest  possible 
nature. 

Here  is  Ballance's  classification  of  intracranial  tumors,  the  majoiity 
of  which  are  of  surgical  importance: 

INTRACRANIAL  TUMORS. 
I.  Epiblastic  tumors: 

A.  (Vrclji-omii. 

B.  Glioma,  gliosarcoma,  anirioglioma. 

C.  Kjiithelioma.     Dtnolopod  from  tlio  cintlicHum  of  the  epondyma,  the 

choroitl  plexus,  the  pineal  gland,  or  the  pituitaiy  body. 

D.  Cholesteatoma  vera. 
II.  Mesoblastic  tumors: 

A.  Sarcoma — of  skull,  of  meninges,  of  brain  substance  (probably  arising 

from  the  walls  of  the  intracerebral  vessels),  of  the  pineal  gland,  of 
the  pituitary  body. 

B.  Endotlielioma^meningeal  (the  fibroplastic  tumor  of  Lebert). 

C.  Fibroma;  fibrosarcoma. 

D.  Psammoma;  angiolithic  sarcoma. 

III.  Secondary  tumors;  metastases  from  carcinoma  or  sarcoma  of  other  regions. 

IV.  Cysts:  Simjjle  cysts,  hemorrhagic  cysts,  parasitic  cysts,  intra-  and  extra- 

dural dermoids. 
V.  Tuberculous  tumors. 
\T.  Gummata. 
VII.  Vascular  tumors — aneurysm. 

Of  all  these  tumors,  the  infectious  granulomata  (tuberculous  and 
syphilitic)  are  far  the  most  common  in  our  records.  The  tuberculomata 
are  usuall_y  multiple,  varying  in  size,  and  with  a  thick  capsule  which 
lends  itself  to  enucleation.  These  tumors  are  most  common  in  the  cere- 
bellum and  in  children.  Syphilomata  are  most  common  in  adults  and 
are  resistent  to  medication.  They  are  dense,  usually  superficial,  some- 
times large  and  multiple ;  often  they  may  be  removed  easily. 

The  commonest  forms  of  true  neoplasms  are  the  endotheliomata, 
loosely  attached,  encapsvdated,  meningeal  tumors  which  do  not  form 
metastases.  They  do  their  damage  by  pressure.  A  common  seat  is  in 
the  cerebellopontine  recess,  and  they  are  favorable  growths  for  excision. 

Gliomata  form  a  class  by  themselves.  They  are  of  the  epiblastic 
type,  and  arise  from  the  neurogliar  connective  tissue.  They  are  soft, 
infiltrating  growths,  which  may  reach  an  enormous  size  and  may  degen- 
erate and  become  cystic.  They  are  vascular  and  frequently  are  the 
seat  of  hemorrhages,  so  that  a  so-called  ''  stroke  of  apoplexy  "  may  be 
the  first  indication  of  their  presence. 

Cystic  tumors  of  a  parasitic  type  (echinococcal  or  hydatid)  or 
traumatic  cysts  occasionally  are  reported.  They  also  give  pressure 
symptoms,  and  may  appear  in  any  part  of  the  brain. 

Such  are  the  commoner  forms  of  brain  tumor.  Besides  these,  brain 
cancers  occur,  usually  from  metastasis,  and  true  sarcomata  as  well. 

We  know  little  of  the  cause  of  the  various  primary  tumors  beyond 
the  fact  that  great  numbers  apparently  owe  their  origin  to  some  cranial 
injury.  The  brain  may  be  greatly  displaced  by  these  gi-owths,  more 
especially  the  cerebellar  growths,  and  the  crowding  down  of  the  cerebel- 
lum and  medulla  into  the  foramen  magnum,  which  follows  lumbar 


TUMORS   OF  THE   BRAIN  055 

puncture  in  certain  cases  of  brain  tumor,  probably  accounts  foi'  the 
sudden  deaths  reported  as  following  this  little  operation. 

In  arriving  at  the  diagnosis  of  intracranial  tumors  we  study  the 
symptoms  muler  two  headings:  general  symptoms  due  to  the  increase 
of  intracranial  tension;  and  special  or  localizing  symptoms,  which  depend 
upon  the  part  of  the  brain  involved. 

The  general  symptoms  of  brain  tumor  are  those  which  we  should 
expect  fron:i  our  knowledge  of  intracranial  pressure.  The  presence  of  a 
slowly  growing  tumor  raises  gradually  the  intracranial  tension,  so  that 
commonly  we  do  not  see  those  acute  alarming  symptoms  which  are  pro- 
duced by  the  sudden  pressure  of  a  fresh  intracranial  hemorrhage. 
Though  the  symptoms  of  brain  tumor  develop  gradually,  and  though 
the  tumor  may  cause  actual  destruction  of  brain  tissue,  either  by  pressure 
or  invasion,  in  the  end  severe  and  alarming  symptoms  develop  which 
end  only  in  death.  The  general  pressure  symptoms,  then,  are  headache, 
nausea  and  vomiting,  and  choked  disk  ending  in  blindness.  Observe 
especially  that  many  of  the  symptoms  of  acute  lesions  are  absent — 
a  high  blood-pressure,  a  slow  pulse,  and  stertor. 

These  general  symptoms,  without  localizing  signs  indicating  the 
position  of  the  tumor,  may  be  present  irrespective  of  the  size,  shape,  and 
place  of  the  growth.  Frequently  one  may  feel  sure  of  the  presence  of  a 
tumor,  but  may  be  quite  unable  to  name  its  location  when  it  lies  in  a 
so-called  "  silent  area"  of  the  brain.  Moreover,  a  minute  tumor  may 
obstruct  the  foramina  and  cause  an  internal  hydrocephalus,  with  result- 
ing general  symptoms,  but  no  localizing  signs.  Consequently,  tumors 
lying  below  the  tentorium  may  lead  early  to  pressure  symptoms,  while 
frontal  tumors  may  cause  no  disturbance  until  they  have  reached  a  con- 
siderable size. 

The  headache  due  to  pressure  upon  the  dura  or  its  expansions  is 
usually  dull  and  diffuse,  but  may  be  insufferably  violent.  The  vomiting 
may  be  frequent  or  rare,  and  is  irrespective  of  food.  Choked  disk  is 
probably  due  to  mechanical  pressure,  to  the  stasis  of  cerebrospinal  fluid 
leading  to  the  optic  sheath,  and  consequent  destruction  of  the  nerve. 
For  this  reason  the  term  optic  neuritis  obviously  is  not  justified.  One  or 
more  of  these  general  symptoms  may  be  lacking  in  cases  of  brain  tumor, 
though  some  degree  of  headache  is  usual,  especially  as  a  late  symptom. 

Localizing  symptoms  may  or  may  not  be  present,  as  we  have  seen; 
and  their  localization  depends  obviously  upon  the  tumor's  presence 
within  or  near  the  various  cortical  centers  which  we  have  already  studied. 
Localizing  symptoms  may  appear  early,  resulting  in  such  phenomena 
as  Jacksonian  epilepsy  or  focal  palsy,  which  should  lead  the  surgeon 
to  a  prompt  exploration.  So  far  as  regards  cortical  growths,  it  is  need- 
less here  to  dwell  further  upon  the  phenomena  which  they  excite. 
Tumors  of  the  basal  ganglia,  if  they  lead  to  pressure  on  the  internal  cap- 
sule, produce  hemiplegia,  hemianesthesia,  hemiataxia,  or  hemianopsia. 
Lesions  of  the  thalamus  frequently  cause  athetoid  movements  or  tremor 
of  the  opposite  limb.  The  deep  reflexes  may  be  increased;  the  super- 
ficial may  be  absent — Babinski's  toe  phenomenon  in  particular.   Tumors 


656 


THE    HEAD    AND    SPINE 


of  the  corpora  quadrigcniina  load  to  a  stajijioring  gait,  to  a  tendency  to 
fall  to  one  side  and  backward,  to  a  failuie  of  sight  and  hearing,  and  to 
sundry  palsies  of  the  eye  muscles.  Tumors  of  the  crura  cerebri,  of 
the  pons,  and  elsewhere  in  the  midbrain,  are  not  accessible  for  removal, 
and  usually  are  unsuitable  for  decompression,  according  to  Cushing, 
because  they  lead  to  obstructive  liydrocephalus,  which  renders  ineffectual 
the  usual  palliative  measures. 

Cerebellar  tumors  are  frequent.  Often  they  are  accessible,  and 
are,  as  a  rule,  localizable.  Early  thej^  cause  general  symptoms  from 
closure  of  the  iter,  so  that  there  results  choked  disk.  We  must  dis- 
tinguish between  extra-  and  intracerebellar  tumors.     The  latter  (intra- 


•T^mir*^.^ 


H. 


Fig.  423. — Case  of  cerebellar  tumor.     Note  dull  faoies  and  expre.ssion  of  eyes  (Massa- 
chusetts General  Hosjntal). 

cerebellar)  cause  pressure  symptoms,  but  they  cause  vertigo  also,  with 
the  apparent  movement  of  the  individual  or  of  surrounding  objects. 
There  are  focal  symptoms — muscular  disturbances  on  the  same  side  of 
the  body  as  the  lesion;  a  staggering  gait,  a  tendency  to  fall  toward  the 
affected  side,  nystagmus,  tilting  of  the  head,  and  occasional  convulsions. 
Often  there  is  local  tenderness  under  the  occiput.  Cranial  nerve  s}-mp- 
toms  usually  are  absent.  Extracerebellar  tumors,  on  the  other  hand, 
produce  cranial  nerve  s\mptoms.  Those  tumors  which  are  removable 
frequently  lie  in  the  cerebropontine  recess.  They  are  supposed  to  arise 
from  the  acoustic  nerve,  so  that  tinnitus  with  one-sided  deafness  is  often 
the  first  symptom.     They  enlarge  slowly  and  may  last  for  years,  with 


TUMORS    OF   TIIK    UKAIN  .057 

resultiiiii'  pressure  paralyses  of  the  fiicijil,  iibducens,  or  trigeminal  nerves. 
Eventually,  they  nui}'  close  the  itei".  Pituitary  body  tumors,  lying  back 
of  the  optic  chiasm,  affect  the  fibers  passing  to  the  inner  side  of  each 
retina,  antl  lead  to  bitemporal  hemianopsia.  Acromegaly  may  be 
associated  with  pituitary  tumors,  severe  headache  is  common,  and 
vomiting. 

We  see  then  that  there  may  be  a  great  variety  of  definite  symptoms, 
a  puzzling  absence  of  symptoms,  and  a  confusing  presence  of  contra- 
dictory symptoms  when  we  undertake  the  diagnosis  of  brain  tumors. 
Moreover,  certain  other  lesions  may  simulate  tumors- — abscess,  gumma, 
hydrocephalus,  and  the  cerebral  symptoms  of  chronic  nephritis. 

The  course  of  brain  tumors  varies  obviously  with  their  nature  and 
their  location.  A  non-malignant  tumor  may  progress  slowl}^  and  exist 
for  3"ears  without  special  disturbance  if  it  be  located  in  a  silent  area. 
On  the  other  hand,  an  infiltrating  tumor  (glioma)  may  progress  rapidly 
from  the  start.  Writers  describe  relief  of  pressure  by  natural  processes 
— rare  processes,  indeed — either  in  childhood,  by  separation  of  the  cra- 
nial bones  and  protrusion  of  the  tumor;  or  an  any  time  of  life,  by  de- 
traction of  the  overhang  skull  through  atroph}'  and  extrusion  of  the 
tumor.  The  average  duration  of  life  in  cases  of  brain  tumor  is  estimated 
at  three  years. 

The  treatment  of  brain  tumors  has  only  recently  begim  to  emerge 
from  a  position  of  almost  hopeless  chaos,  and  to-day  even  many  com- 
petent general  surgeons  are  skeptical  of  any  practical  benefit  from  opera- 
tions. I  cannot  believe  that  their  attitude  is  justified.  A  little  retros- 
pection reminds  us  of  many  other  surgical  conditions  now  benefited 
by  operation,  toward  which  operations  the  profession  was  long  skeptical. 
And  disease  of  the  brain  furnishes  a  branch  of  surgery-  peculiarly  diffi- 
cult of  diagnosis  as  well  as  of  operative  treatment. 

In  general  terms,  w'e  have  now  three  well-recognized  measures  at 
command  for  our  attack  upon  brain  tumors — medicinal  treatment, 
palliative  operative  treatment,  and  curative  operative  treatment. 

Medicinal  measures  are  sometimes  extremely  efTective,  but  are  effec- 
tive in  the  case  of  one  class  of  tumors  only — syphilitic  gummata.  We 
have  seen  that  gummata  are  common.  Sometimes  it  is  easy  and  con- 
soling for  the  practitioner  to  persuade  himself  that  the  suspected  tumor 
is  a  gumma.  Often  he  relieves  the  symptoms  by  a  vigorous  course  of 
potassium  iodid.  But  let  him  bew-are  of  overconfidence  and  of  incon- 
siderate overdrugging.  If  the  symptoms  do  not  promptly — within  the 
month — show^  signs  of  abating,  he  must  reflect  that  the  tumor  is  either 
not  a  gumma  or  is  a  gumma  of  such  a  character  that  potassium  iodid 
will  not  dissipate  it.  Moreover,  let  him  not  neglect  the  condition  of 
the  patient's  eyes.  In  the  case  of  a  gumma  even  there  may  be  so  long 
a  delay  in  the  relief  of  pressure  through  medication  that  the  affected 
optic  nerves  may  go  on  to  complete  degeneration,  so  that  the  patient  is 
cured  of  his  tumor,  but  is  left  blind.  A  prompt  decompressive  operation 
might  have  relieved  the  choked  disk  and  have  saved  the  eye-sight. 

Palliative  decompressive  operations  are  extremely  valuable  in  nearly 
42 


658  THE    IlKAD    AND   Sl'l.NE 

all  classes  of  brain  tumors  except  those  which,  thi-ough  pressure  upon 
the  iter,  have  caused  an  obstructive  hydrocephalus.  In  these  cases  the 
newly  formed  cranial  defect  gives  but  temporary  rehef,  if  any;  more 
fluid  accumulates  in  the  ventricles,  and  the  old  high  tension  returns. 
In  many  cases  of  Ijrain  tumors,  however,  decompression  gives  brilliant 
results,  even  though  the  patient  eventually  die,  uni'elieved  of  his  tumor. 
After  the  decompi-ession,  headache  disappears,  vomiting  ceases,  the  eye- 
sight is  restored,  paralytic  conditions  improve,  and  often  the  patient 
is  enabled  for  a  year  or  more  comfortably  to  go  about  his  business. 
The  undiscovered  tumor  may  continue  to  grow,  but  the  great  gap  in  the 
skull  provides  for  escape  of  the  brain  as  a  heniia,  and  the  old  intra- 
cranial tension  does  not  return. 

These  palliative  operations  are  undertaken  in  the  case  of  presenting 
irremovable  tumors  as  w^ell  as  of  those  which  cannot  be  localized.  The 
surgeon  should  take  some  pains  in  selecting  the  site  for  decompression, 
because  the  extruded  brain  is  wont  to  become  more  or  less  functionless. 
As  a  general  rule,  therefore,  one  should  operate  over  a  silent  area,  in 
right-handed  patients,  under  the  right  temporal  muscle  in  case  of  a 
cerebral  tumor,  and  under  the  suboccipital  muscles  in  case  of  a  sub- 
tentorial  growth. 

Curative  operations  are  rare,  but  with  increasing  exj^erience  such 
surgeons  as  Victor  Horsley,  Gushing,  Ballance,  and  others  are  demon- 
strating that  certain  varieties  of  tumors  may  be  removed  entire,  with 
a  fair  chance  of  permanent  cure.  As  Gushing  says,  certain  important 
questions  are  always  raised  in  case  one  is  able  to  cut  down  upon  and 
explore  a  tumor  of  the  brain:  What  is  the  tumor's  nature?  how  great 
a  loss  of  function  has  it  produced  already?  will  its  removal  result 
in  the  improvement  or  in  the  increase  of  sj-mptoms  already  present? 
One  may  not  answer  accurately  these  queries  in  every  case,  but  we  may 
state  in  general  terms  that  an  encapsulated  tumor  can  be  removed 
entire,  while  an  infiltrating  tumor  must  be  left  in  part.  There  may 
result  immediately  an  increase  in  functional  disturbances,  but  growing 
experience  in  operations  and  through  animal  experimentation  has  de- 
monstrated that  damaged  brain  often  shows  a  surprising  power  of  re- 
establishing function  apparently  lost. 

RESULTS   OF   INJURIES   AND  DISEASES   OF  THE  BRAIN 

Before  considering  in  more  detail  methods  of  operating  upon  the 
brain,  let  us  observe  hei-e  certain  results  of  injuries  and  diseases  of  the 
brain. 

Hernia  cerebri  and  fungus  cerebri  are  sequela^  of  quite  different 
types,  though  their  nature  has  often  been  misunderstood.  Heniia  is 
due  to  pressure  from  within,  and  is  a  proti-usion  of  normal  brain,  covered 
with  sound  skin.  A  fungus  is  a  protioision  of  brain  through  an  open 
wound  in  the  scalp — a  serious  condition,  owing  to  the  prospect  of  infec- 
tion and  meningitis. 

Gushing  calls  attention  to  the  existence  of  a  wide-spread,  but  curi- 


RESULTS  OF  INJURIES  AND  DISEASES  OF  THE  BRAIN 


659 


ously  erroneous,  notion  that  mere  exposure  of  the  brain,  on  opening 
the  dura,  will  alwaj's  lead  to  a  protrusion  of  brain  through  the  dural 


Fig.  424. — Fungus  cerebri  following  exploration  of  brain  (Massachusetts  General 

Hospital). 


Fig.  425. — Hernia  cerebri. 


opening.  Quite  othenvise  is  the  fact,  for  normally  the  brain  recedes 
when  exposed,  owing  to  atmospheric  pressure.  Under  certain  circum- 
stances, however,  the  brain  will  protrude — perhaps  from  the  presence 


660  THE    HEAD    AND    SPIXE 

of  a  tumor,  perhaps  from  venous  stasis,  i)eihaps  from  an  improper 
handling  of  the  cortex,  leading  to  edema  and  increased  pressure.  Under 
these  conditions  the  surgeon  ma}-  find  it  impossible  accurately  to  re- 
place the  dura,  but  generally  relief  of  tension  ma}-  be  secured  In- 
elevating  the  head,  b}-  pricking  the  arachnoid  so  as  to  allow  cerebro- 
spinal Ihiid  to  escape,  or,  if  necessary,  by  a  lumlxir  puncture.  The 
hernitc  established  by  decompression  may  reach  enormous  size,  especi- 
ally if  they  are  unprotected  by  overlying  muscle.  In  these  days  a  fungus 
rarely  is  seen. 

Epilepsy. — This  is  no  place  in  which  to  discuss  fully  that  most  diffi- 
cult and  often  indeterminate  disease,  characterized  by  the  symptom- 
complex  convulsions,  and  conveniently  called  epilepsy.  "Epilepsy" 
itself  is  no  proper  term  to  designate  the  disease.  Epilepsy — a  ''  falling 
on" — is  but  a  s>'mptom.  The  causes  of  many  epileptic  or  epileptiform 
attacks  are  numerous  and  obscure,  varying  from  psychic  disturljunces 
to  true  histologic  changes  in  the  motor  cortex.  We  must  believe  it 
proved  that  certain  reflex  irritations,  as  from  an  ovarian  tumor  or  an 
ingrowing  toe-nail,  may  cause  epileptiform  seizures;  and  certain 
toxemias,  especially  those  occurring  in  renal  disease,  may  lead  to 
convulsions.  Whatever  the  cause  of  the  epilepsy,  it  is  obvious  that 
some  irritation  of  the  cortex,  whether  due  to  psychic  or  mechanical 
causes,  is  at  the  bottom  of  the  attack.  We  are  concerned  here,  however, 
with  those  forms  of  epilepsy  especially  which  are  due  to  definite,  gross, 
organic  lesions,  and  we  must  remember  that  organic  epilepsy,  as  dis- 
tinguished from  idiopathic  epilepsy,  is  characterized  by  focal  or  so-called 
Jacksonian  attacks,  preceded  by  a  more  or  less  definite  aura.  This 
distinction  is  not  always  reliable,  for  cases  of  reflex  epilepsy  even  may 
have  focal  sym'ptoms,  while  actual  organic  cortical  lesions  may  cause 
no  focal  symptoms. 

We  may  not  discuss  here  the  intricate  subject  of  the  causation  of 
epilepsy  further  than  to  remind  the  reader  that,  in  addition  to  the  well- 
recognized  etiologic  factors,  epilepsy  may  be  due  to  meningeal  adhesions 
following  meningitis,  to  cerebral  syphilis,  to  brain  tumors,  to  brain 
damage  following  traumatism,  and  especially  to  those  injuries  leading 
to  what  are  known  as  birth  palsies— injuries  to  the  infant's  head  over- 
looked at  birth,  but  leading  later  to  pronounced  nervous  and  mental 
derangements. 

From  what  has  been  said,  and  assuming  the  reader's  general  knowl- 
edge of  the  subject  of  epilepsy,  we  see  that  the  sym'ptoms  which  justify 
a  surgical  operation  are  often  difficult  and  confusing.  Moreover,  we 
must  reflect  that  an  individual  case,  taken  early,  may  be  susceptible  of 
cure  by  operation,  whereas  the  same  patient,  if  left  a  sufferer  for  months 
or  years,  may  not  be  benefited  in  the  least  by  a  late  operation,  because 
he  has  formed  the  "epileptic  habit."  There  are  sundry  types  of  epi- 
leptics whom  operations  may  benefit,  especially  those  persons  suffering 
from  so-called  Jacksonian  attacks — attacks  beginning  with  a  distinct 
aura  and  marked  by  convulsions  strictly  localized  at  first  to  the  hand 
or  foot,  and  later  perhaps  becoming  general.     Then  there  are  the  cases 


RESULTS    OF    INJURIES    AND    DISEASES    OF   THE    BRAIN  601 

in  which  the  seizui'o  is  general  from  the  outset,  though  these  cases 
themselves  may  earlier  in  their  careers  have  been  marked  by  distinctly 
focal  symptoms.  The  cases  of  focal  epilepsy — Jacksonian — appear  to 
be  due  to  a  cortical  irritation  occasioned  by  some  form  of  obvious 
lesion — depressed  bone,  meningeal  adhesions,  a  tumor.  Those  cases 
distinguished  b}'  general  convulsions  may  likewise  be  due  to  focal  irrita- 
tions, and  it  is  in  this  class  that  we  nuiy  often  group  that  large  number  of 
birth  palsies  sometimes  called  idiopathic  cases. 

The  treatment  of  epilepsy  is  operative  so  far  as  the  surgeon  is  con- 
cerned, though  there  are  cases  which  undoubtedly  have  been  greatly 
benefited  after  operation  by  resorting  to  the  use  of  bromids  or  psycho- 
therapy in  order  to  break  up  the  epileptic  habit. 

There  is  a  diversity  of  opinion  as  to  what  should  be  the  nature  of 
an  operation  upon  tlie  brain  for  epilepsy.  One  fact  is  certain,  that 
the  old-fashioned,  small  trephinings,  the  peeping  at  the  brain  through 
a  little  hole,  and  the  scratching  of  the  arachnoid  with  a  needle-point, 
are  of  little  benefit.  The  main  reason  for  discouragement  over  the 
history  of  the  operative  treatment  of  epilepsy  lies  in  the  fact  that  the 
operations  have  been  utterlj-  inadequate.  Whatever  the  nature  of  the 
intracranial  lesion  may  be,  we  have  not  yet  determined  how  it  affects 
nervous  tissue  so  as  to  produce  convulsions.  There  are  those  who 
believe  that  the  presence  of  an  adhesion  alone  is  sufficient  cause  for 
irritation  leading  to  convulsions.  There  are  others,  notably  Kocher, 
who  assume  that  the  local  lesion  in  itself  is  non-irritating  except  when, 
from  any  cause,  a  slight  increase  in  the  intracranial  tension  induces  a 
special  irritation  at  the  site  of  the  local  lesion.  My  own  experience  in 
operating  for  epilepsy  leads  me  to  agree  with  the  teachings  of  Kocher. 
AVhatever  one's  views  on  this  difficult  point,  all  competent  surgeons 
are  now  agreed  that  in  operating  we  should  cut  down  on  the  brain 
through  a  large  bone-flap.  Horsley,  Gushing,  and  others  have  con- 
ducted considerable  operations  upon  the  meninges  and  the  brain  itself 
for  epilepsy,  going  so  far  even  as  to  remove  small  areas  of  the  cortex 
which  were  thought  responsible  for  the  focal  sj'mptoms.  Other  sur- 
geons have  contented  themselves  with  removing  obvious  abnormalities, 
and  trusting  to  extensive  decompressive  measures  to  lighten  the  brain 
of  future  pressure  and  local  irritation.  This  last  is  Kocher's  teaching. 
Certain  it  is  that  through  both  methods  great  numbers  of  patients 
have  been  improved  or  cured.  Mark  the  distinction  in  the  methods 
of  finishing  the  operation.  By  the  Horslej'  method  the  dura  and  bone 
are  carefully  returned  into  place.  By  the  Kocher  method  the  dura  is 
replaced,  but  the  bone-flap  is  removed  entirely.  A  great  deal  has  been 
said  and  written  regarding  the  importance  of  replacing  smoothly  and 
accurately  the  dura.  In  two  cases  I  have  been  obliged  to  remove 
the  dura,  leaving  the  arachnoid  to  become  adherent  to  the  skin-flaps, 
a  condition  which  is  usually  represented  as  leading  to  serious  subse- 
quent cortical  irritation.  In  both  of  these  cases  no  disturbance  has 
resulted,  as  the  wide  removal  of  bone  provides  for  comfortable  expan- 
sion of  the  brain.     In  spite  of  such  experiences,  however,  sound  practice 


662  THE    HKAI;    AND    SPIXE 

teaches  that  when  it  i?;  possible,  we  should  secure  a  smooth  replacement 
of  the  dura  in  order  to  avoid  adhesions.  The  conditions  one  finds 
within  the  skull — the  conditions  presumably  causative  of  the  epilepsy — 
are  numerous,  and  sometimes  obscure  and  puzzling.  Depressed  frag- 
ments of  bone,  adhesions,  and  tumors  are  ob\ious  enough,  but  fre- 
quently one  finds  nothing  beyond  a  wide  and  somewhat  indefinite 
thickening  of  the  arachnoid,  giving  to  its  surface  a  slight  bulging  a.'<pect 
and  a  pearly  blue  color.  Freciuently  surgeons  fail  to  recognize  this 
as  an  abnormal  condition.  In  fact,  the  condition  is  one  of  thickening 
of  the  arachnoid,  due  probably  to  a  long  antecedent  cortical  hemon-hage. 
One  questions  whether  such  an  obscure  cause  as  this  may  not  explain 
certain  types  of  so-called  idiopathic  epilepsy.  This  condition  of  thick- 
ened arachnoid  may  be  benefited  by  tearing  the  arachnoid  with  a  needle- 
point in  several  places  and  so  permitting  the  escape  of  cerebrospinal 
fluid.  Surprising  improvement  sometimes  follows  this  operation,  whose 
advantages  may  be  due  to  an  alteration  established  in  the  cortical  circu- 
lation. My  personal  inclination  in  such  cases  is  to  complete  the  opera- 
tion by  decompression. 

After  operation  these  patients  should  be  handled  with  the  greatest 
care.  The  wound  should  be  sewed  up  dry  and  drained  with  mbber 
tissue.  The  patient  should  lie  with  the  head  slightly  elevated.  His 
room  should  be  kept  at  a  moderate  temperature,  and  with  strong  light 
excluded;  noisy  and  inconsiderate  attendants  should  be  kept  at  a  dis- 
tance, and  rest  in  bed  should  be  enjoined  for  three  or  four  weeks.  At  the 
same  time  the  diet  should  be  carefully  regulated  and  the  bowels  should 
be  moved  daily.  If  the  surgeon  can  find  time  for  the  extra  attention, 
he  may  greatly  relieve  the  strain  upon  the  patient  and  facilitate  the  con- 
valescence by  gentle  suggestive  treatment,  which  should  encourage  the 
patient  to  look  for  a  restoration  of  health. 

There  are  sundry  other  disabilities  and  serious  complications  which 
are  associated  with  cranial  injuries  and  intracranial  disease — psycho- 
ses, insanity,  imbecility,  alterations  of  temperament  and  intellect. 
A  discussion  of  these  far-reaching  topics  is  impossible  here,  further  than 
to  state  that  such  mental  disabilities  sometimes  are  remedied  by  suitable 
operations,  especially  by  decompressive  operations.  I  believe  that  all 
cases  of  intellectual  impairment  which  can  be  traced  directly  to  causa- 
tive head  injuries  should  have  the  benefit  of  a  surgical  operation. 

A  few  years  ago  we  were  told  that  certain  cases  of  insanity  and  con- 
genital imbecility  are  due  to  permanent  closure  of  the  cranial  sutures, 
this  closure  producing  a  crowding  and  a  checking  of  development  of  the 
brain.  Surgeons  endeavored  to  remedy  the  condition  by  establishing 
artificial  sutures  and  so  promoting  cerebral  grow^th.  These  conceptions 
and  endeavors  have  been  shown  to  be  without  value  and  inconsistent 
with  just  reasoning,  and  we  now  know  that  the  process  is  the  reverse 
of  what  was  assumed ;  an  early  closure  of  fontanel  and  suture  is  due  to  a 
primary  failure  of  growth  of  the  encephalon. 

Operations  have  been  found  useless  in  the  case  of  these  unfortunate 
persons.     Those  victims  who  are  not  hopelessly  imbecile  may  be  taught 


INTRACRANIAL   OPKRATIOXS  663 

simple  tasks,   and  may  possibly  attain  to  self-support   through  the 
schools  for  feeble-minded. 

Cranial  defects,  cspefiall\-  those  defects  due  to  injuries  and  opera- 
tions, have  been  the  suljjcct  of  considerable  discussion,  and  many  sur- 
geons have  maintained  that  these  defects  may  lead  to  serious  cerebral 
disturbances,  such  as  epilepsy,  and  that  they  should  be  closed.  I  am 
not  convinced  that  this  conclusion  is  justified  by  the  facts.  Certainly 
operations  for  decompression  of  the  brain  are  demonstrating  that  skull 
defects  in  themselves  are  often  a  benefit.  It  is  not  impossible  that  in 
those  cases  of  skull  defects  which  are  associated  with  cerebral  distur- 
bances the  irritation  may  be  due  to  thick  adhesions  or  to  lack  of  proper 
decompression.  On  the  other  hand,  Dudley  P.  Allen  has  been  able 
to  rej^ort  the  records  of  certain  patients  affected  with  epilepsy  associated 
with  skull  defects  who  have  been  benefited  bj'  closing  the  defects  with 
bone-flaps.  I  am  myself  inclined  to  adopt  the  view  of  Cushing,  "  that 
closure  of  a  defect  should  be  limited  to  those  cases  in  which  it  is  in  an 
obtrusive  situation  and  makes  an  unsightly  deformity;  to  those  in  which 
local  pain  or  tenderness  promises  to  be  lessened;  or  occasionally  when 
the  patient  has  an  associated  obsession  in  regard  to  its  presence." 

INTRACRANIAL  OPERATIONS 

The  technic  of  intracranial  operations  is  still  a  subject  of  considerable 
debate.  I  shall  not  endeavor  to  describe  in  detail  the  various  methods 
which  are  advocated  by  various  surgeons,  but  shall  content  myself  with 
explaining  the  method  which  I  myself  use, — essentially  the  method  of 
Harvey  Cushing.^ — observing  at  the  same  time  that  this  method  itseK 
Taax  soon  become  antiquated.  It  is  not  difficult;  it  is  somewhat  slow; 
it  is  reasonabh'  safe. 

A  striking  and  fundamental  distinction  exists  between  present  meth- 
ods of  opening  the  skull  and  all  those  methods  in  use  up  to  fifteen  years 
ago.  Throughout  surgical  history'  the  mere  piercing  of  the  skull, 
especially  when  associated  with  opening  the  dura,  was  regarded  as  a  most 
serious  undertaking;  and  the  constant  endeavor  of  surgeons  was  to  make 
the  opening  as  small  as  possible.  To  this  end  they  used  small  trephines; 
they  shrank  from  injuring  the  dura;  they  looked  in  through  little  holes 
at  the  membranes  and  the  brain ;  they  saw  little,  and  their  endeavors 
were  generally  ineffective.  In  speaking  of  epilepsy,  I  explained  how  it 
is  that  these  insufficient  operations  seldom  resulted  in  the  accomplish- 
ment of  good.  Xot  only  did  they  fail  to  afford  space  sufficient  for  proper 
inspection,  but  the}'  failed  to  accomplish  the  relief  of  pressure  or  to  give 
room  for  the  removal  of  adhesions,  of  cysts,  and  of  tumors. 

The  osteoplastic  craniotomy  is  the  operation  of  to-day,  and  is  an 
immense  advance  in  the  surgery  of  the  head.  It  consists  in  turning 
back  a  large  disc  of  bone  (as  large  even  as  the  palm  of  the  hand)  with  the 
overlying  skin-flap. 

Careful  surgeons  themselves  attend  to  certain  details  of  the  prepara- 
tion for  operation.    So  far  as  ma}'  be,  the  patient  should  be  brought  to  the 


V){\i 


THK    IIKAD    AXD    SPIXE 


table  ill  a  placid  .state  of  iiiiiid  and  Ixxly.     A  normal  iiHA-eiiieiit  of  the 
bowels   is  important,   but    ])reliniinary  drastic   jmi-.ucs  are  an  offense. 


Fig.  426. — Opening  the  skull — step  1  (("usliing  in  Keen's  Surge ly). 


Fig.  427. — Opening  the  skull — step  2.  Dahlgren  forceps  used  for  incision  of 
lateral  edges  of  Ijone-flap  Avhen  approaching  thinner  jiortion  of  cranium  in  temj)oral 
region  (Gushing  in  Keen's  Surge rj-)- 

The  patient's  head  should  be  shaved  completely  and  this  should  be 
done  deftly  and  gently,  preferably  on  the  operating  table.  Then  the 
anesthetic  should  be  given,  and  for  this  I  use  ether.     With  the  patient 


INTRACRANIAL   OPERATIONS 


665 


unconscious,  cleanse  the  skin,  and  over  the  whole  head  throw  a  wet 
bichlorid  compress;  then  pass  about  the  head,  from  inion  to  glabella,  the 
rubber  tourniquet  which  shall  control  the  vessels  of  the  scalp.  The 
patient  should  lie  upon  the  table  in  the  position  most  favorable  for  opera- 
tion, and  as  a  routine  he  should  be  elevated  in  a  modified  Fowler's  posi- 
tion, as  hemorrhage  is  thus  controlled  more  easily.  I  use  the  pneumatic 
suit  with  a  view  to  counteract  the  shock,  and  in  a  few  cases  have  found 
it  valuable. 

With  the  patient  anesthetized  and  with  the  field  clear  (and  be  it  re- 
marked that  a  specially  skilled  anesthetist  is  a  desideratum),  turn  down 


Fig.  42S. — Opening  the  skull — step  3.  Showing  Gigli  wire  saw  in  use  for 
making  beveled  mesal  edge  of  flap,  with  dural  guard  introduced  through  the  two 
cranial  openings  (Cushing  in  Keen's  Surgery). 

a  large  skin-flap,  carrying  the  knife  directly  and  firmly  to  the  bone.  The 
hemorrhage  should  be  slight,  or  there  should  be  none  at  all.  Open  the 
skull  through  two  half -inch  trephine  openings  at  the  upper  angles  of  the 
flap.  Gnaw  away  the  bone  with  De"\'ilbiss  forceps,  from  the  trephine 
openings  downward,  making  the  lines  of  opening  approach  each  other 
somewhat,  and  then — a  most  important  step — complete  the  section  by 
sawing  away  the  bone,  on  the  bevel,  between  the  trephine  openings. 
We  accompHsh  this  best  by  the  use  of  a  Gigli  saw,  passed  along  a  large 
grooved  director  between  the  bone  and  dura  from  one  opening  to  the 
other.     The  Gigli  saw  is  made  to  divide  the  bone  on  the  bevel  in  order 


066  THE    HEAD    AXD    SPIXE 

that  when  the  bone-flap  is  replac-ctl,  the  bone  shall  rest  in  its  bed  without 
pressing  clown  upon  the  underlying  bi'ain.  Various  other  methods  of 
cutting  through  the  skull  are  favored  b}^  vaiious  surgeons,  who  use  in- 
genious saws  and  osteotomes.  These  are  useful  instruments  in  the 
hands  of  experts,  but  I  believe  that  the  method  1  have  described  here  is 
the  simplest  and  most  generally  applicable. 

The  bone  being  divided,  the  bone-flap  is  completed  by  forcing  an 
instrument  beneath  the  calvarium  and  breaking  back  the  flap,  which 
falls  over  on  its  hinge  of  scalp.  The  surgeon  may  now  proceed  to  inspect 
the  dura,  and  to  open  it  through  the  large  bonc^  window  he  has  i:»rovided. 
In  opening  the  dura  take  great  pains  not  to  wound  the  thin-wafled  and 
delicate  vessels  of  the  pia.     If  they  must  be  cut,  hcmon'hages  should  be 


i^^^W           /''Ir^-'^^^^^k^^fl^. 

'  "^^kfc^iiK^Jv:.    \ V 

H^k^ 

k 

i^^    -                  f      :  .  m^KMK^^W^ '    /J^^^^^ 

^^^:v 

^ 

V  -^c^*^^^/   '!* 

Wn- 

1 

•k'               '-^^  -i 

S^ar^' 

1 

▼                   >  >^1 

.JH 

i 

Fig.  429. — Opening  the  skull — .step  4.  Osteopla.stio  flap  and  dura  refleeted. 
Note  broad  level  of  Uf)per  edge  of  bone-flap,  also  concentric,  rather  tl'an  superim- 
posed, openings  througli  scalp,  cranium,  and  dura  (Cushing  in  Keen's  .Surgerj-). 

controlled  near  the  site  of  their  section  b}'  delicate,  split,  black  silk  liga- 
tures, needled  around  the  vessels,  and  not  b}'  hemostatic  forceps.  In- 
deed, in  all  these  manipulations  of  the  membranes  and  cortex  the  greatest 
delicacy  of  touch  should  be  practised.  Rough  handling  ma}'  frustrate 
all  our  purposes  by  stimulating  hemorrhage  and  even  by  bringing  about 
a  troublesome  edema.  If  the  patient's  blood-pi'essure  falls  after  the 
skull  is  opened,  and  if  signs  of  shock  appear,  it  is  proper  to  close  the 
wound  and  to  complete  the  operation  some  days  later — indeed,  some 
surgeons  employ  two  or  three  sittings  as  a  routine  measure. 

The  closure  of  the  wound  is  an  important  step,  not  to  be  slurred, 
Whenever  possible,  the  dura  should  be  accurately  and  carefully  stitched 
into  place.     When  permanent  decompression  is  required,  this  replacing 


IXTRACKANIAL  Ol'EKATIOXS 


(){)', 


of  the  durii  may  be  inadvisable,  and  if  the  dura  is  to  be  removed,  it  should 
be  trimmed  away  close  to  the  bones'  edge,  lest  pressure  from  within  crowd 
it  against  the  rough  bone  and  cause  troublesome  headache.  Then  one 
should  suture  the  scalp  accurately  and  carefully  in  its  turn,  and  I  be- 
lieve it  is  best  to  control  all  superficial  bleeding  points  in  the  scalp  be- 
fore suturing  is  done.  If  drainage  must  be  established,  we  should  use 
cigaret  wicks  led  out  through  a  special  stab-wound  beyond  the  edge  of 
the  skin  incision,  and  as  low  down  on  the  head  as  may  be.  Finall}-, 
the  head  should  be  dressed  in  an  abundant  absorbent,  elastic  com- 
pression dressing,  to  be  changed  on  the  third  day,  when  all  stitches  and 
drains  should  be  removed.     After     ^ —  — r^       ,   ^.. .  ... 


all  operations  on  the  brain,  and  es- 
pecially after  traumatic  lesions,  give 
the  patient  urotropiii  (gr.  7^  t.  i.  d.), 
which  shall  anticipate  and  check 
any  possible  infection. 

Decompressive  operations, 
whene\-er  possible,  should  be  done 
through  muscle  tissue.  For  ex- 
ample, in  case  the  surgeon  plans  a 
decompression  to  palliate  the  symp- 
toms of  a  cerebral  tumor  of  un- 
knoT\-n  site,  he  ma}*  make  his  open- 
ing through  the  squamous  portion 
of  the  temporal  bone,  and  approach 
that  bone  by  splitting  the  temporal 
muscle.  B}'  this  maneuver  one 
may  expose  a  considerable  area  of 
bone,  may  excise  it,  and  may  cover 
in  the  gap  with  temporal  muscle, 
aponeurosis,  and  skin,  thus  delimit- 
ing and  controlling  an  excessive 
hernia. 

Suboccipital  explorations  are 
well  made  through  an  approach  by 

Cushing's  cross-bow  incision.  In  this  fashion,  as  the  drawing  illustrates, 
one  maj^  lay  bare  comfortably  the  lower  portion  of  the  occiput  and  may 
remove  bone,  covering  in  the  gap  subsequently  by  heavy  layers  of  muscle 
and  aponeurosis. 

Surgeons  approach  the  base  of  the  skull  by  other  routes  and  in  other 
quarters — the  anterior  fossa  through  the  temporal  bone  or  even  through 
the  frontal  bone;  and  operators  have  sought  the  pituitary  fossa  by  going 
'directly  under  the  front  allobes  after  turning  down  a  large  frontal  bone- 
flap,  or  by  working  through  the  nasal  passages  and  accessory  sinuses. 
These  operations  about  the  base  are  almost  always  associated  with  ob- 
stinate, and  sometimes  with  serious,  hemorrhage  from  large  veins, 
so  that  the  operations  must  be  undertaken  with  caution,  pains,  and 
discretion.     It  is  not  probable  that  such  difficult  and  delicate  explora- 


Fig.  430. — Cushing's  method  of  clos- 
ing scalp  before  removal  of  tourniquet. 
Note  ridge  of  tissue  made  by  sutures 
when  tied  (.Gushing  in  Keen's  Surgery). 


668 


THE    HEAD    AND    Sl'INE 


tions  will  find  favor  with  <iviieial  surgeons  in  the  near  future.  These 
are  matters  more  partic-ulari}-  for  the  carefully  trained  neurologic 
surgeon. 

At  the  beginning  of  this  chapter  I  made  some  mention  of  the  diflicul  ■ 
ties  and  of  the  promise  of  intracranial  surgeiy.     In  its  modern  aspects 


L 


Fig.  431. — The  suboccipital  exposure,  showing  opening  partly  made,  and  Cushing's 
"  cross-bow"  incision  (C'ushing  in  Keen's  Surgery). 

the  subject  is  a  new  one,  not  altogether  formulated  as  yet,  or  deter- 
mined in  many  of  its  aspects;  but  I  hope  I  have  shown  in  this  brief 
sketch  the  nature  of  what  is  now  being  done,  and  the  purposes  of 
those  men  who  are  skilled  in  this  field,  and  have  made  clear  the  reasons 
of  their  hope  for  the  future. 


CHAPTER  XXV 

THE   SPINE   AND   THE   PERIPHERAL  NERVES 

The  Spine 

The  surgery  of  the  spine,  like  the  surgery  of  the  head,  has  been 
strangeh'  shrouded  in  clouds  and  mystery.  Doubtless,  this  mystery 
has  surrounded  the  surgery  of  the  spine  for  two  excellent  and  inter- 
dependent reasons :  the  anatomy  and  physiology  of  the  nervous  system 
have  not  been  elucidated  until  recent  years;  and  the  surgeon,  when 
he  deals  with  the  spinal  cord  and  its  component  nerve-fibers,  deals  with 
microscopic  structures.  Minute,  numerous,  and  complex  stnictures  are 
our  study,  and  their  functions  are  correspondingly  intricate.  But 
their  arrangement,  so  far  as  it  has  been  explained,  should  no  longer 
baffle  the  intelligent  student.  The  arrangement  of  the  nerve-fibers 
is  no  more  confusing  than  is  the  arrangement  of  tracks  in  a  great  rail- 
way freight  yard;  and  the  study  of  their  function  is  no  more  difficult 
than  is  the  study  of  electric  science. 

Hitherto  the  general  surgeon,  when  confronted  bj^  spinal  lesions, 
has  been  content  to  serve  as  the  tool  of  the  neurologist;  he  has  been 
the  neurologist's  mallet  and  gouge.  The  positions  should  be  reversed, 
and  the  surgeon,  if  he  be  not  himself  a  skilled  neurologist,  should  use 
the  neurologist  as  his  instrument  of  precision — as  his  stethoscope  or 
thermometer.  It  would  seem  as  though  thus  only  can  present  progress 
be  made  in  knowledge  of  the  pathology  and  the  treatment  of  lesions 
of  the  central  nervous  system  in  man.  Through  the  nature  of  his  work 
the  surgeon  seeks  to  excel  in  therapeutics,  and  the  neurologist  in  diag- 
nosis. Special  training  and  study  doubtless  are  needed  to  develop  neu- 
rologic surgery  to  its  maximum,  and,  as  I  remarked  in  speaking  of 
cranial  surgery,  the  expert  neurologic  surgeon  is  still  rare  among  us. 

Surgery  of  the  spine  is  analogous  to  cranial  surgery  in  many  respects. 
The  factor  of  central  interest  is  the  cord  in  the  former  case,  as  is  the 
brain  in  the  latter  case ;  but  mark  this  distinction,  damage  to  the  skuU 
in  itself  is  of  little  consequence  so  long  as  the  brain  be  not  involved; 
but  damage  to  the  vertebrae  may  be  serious,  crippHng,  and  fatal  even, 
though  the  cord  remain  untouched  and  unimpaired.^ 

This  statement  must  not  mislead  the  surgeon,  however,  especially 
when  he  deals  with  traumatic  injuries  of  the  spine.  He  must  investigate 
the  condition  of  the  cord  and  the  spinal  nerves  in  all  spinal  lesions. 

Spinal  surgery,  like  cranial  surgery,  is  no  new  thing.     Its  historj' 
furnishes   a   fascinating   subject   for   the   thoughtful    student.     Galen 
himself,  in  the  second  century,  was  probably  the  first  surgeon  cogently 
1  For  example,  certain  fatal  cases  of  spinal  caries. 

669 


670  THE    HEAD    AND    SPINE 

to  demonstrate  the  functions  of  the  central  nervous  system,  and  the 
relation  between  encephalon,  cord,  and  jjcrij^heral  nerves.  He  recog- 
nized the  tlistinction  between  sensory  and  motor  nerves  also,  and  seems 
to  have  had  some  conception  of  anterior  and  posterior  nerve-roots. 
He  advocated  operating  for  damage  to  the  spine  with  paralA-ses. 
Sundry  others  of  the  ancients  adopted  his  views,  notably  Paul,  of  Egina, 
in  the  seventh  century;  while  throughout  surgical  history  we  find  bold 
men — Pare,  in  the  sixteenth  century,  for  example —  urging  operations 
for  spinal  fractures.  So  we  come  down  the  line,  noting  some  of  the 
great  physiologists  and  surgeons,  Charles  Bell,  Astle}-  Cooper,  Cline, 
Magendie,  Heister,  and  many  such,  until,  by  the  middle  of  the  nineteenth 
century,  surgeons  and  neurologists  alike  are  seen  to  have  become  con- 
vinced that  the  operative  treatment  of  spinal  lesions  has  a  place  in  our 
therapeutics.  In  spite  of  such  conviction,  however,  the  puiposes  of 
neurologic  surgeons  were  long  undirected,  and  their  measures  hap- 
hazard and  largely  futile.  Only  recently-,  out  of  a  growing  clincial  ex- 
perience and  a  better  knowledge  of  phj'siolog}-,  have  we  begun  logically 
to  approach  this  great  field,  as  yet  so  crudely  tilled. 

ANATOMY  AND  PHYSIOLOGY  OF  THE  CORD 

The  anatomy  and  physiology  of  the  cord  and  spinal  nerves  merit 
our  careful  study,  but  space  forbids  more  than  a  passing  glance  here. 
Physiologically,  the  cord  begins  with  the  medulla,  within  the  cranium. 
Surgically,  the  cord  begins  at  the  foramen  magnum,  and  ends  at  the 
tip  of  the  conus  medulla ris,  at  the  upper  border  of  the  second  lumbar 
vertebra;  although  the  terminal  nerves,  the  cauda  equina,  are  given 
off  above  this  point,  opposite  the  bodies  of  the  eleventh  and  twelfth 
dorsal  vertebrae.  The  cauda  ec^uina  itself  is  inclosed  for  a  part  of  its 
course  in  the  dural  pouch,  which  ends  like  a  glove  finger-tip  at  the  second 
sacral  vertebra.  So  the  cord  is  suspended  from  the  brain,  as  it  w^ere, 
but  is  chiefly  supported  and  steadied  by  the  nerve-roots  emerging 
between  the  spinal  vertebrae  and  the  denticulate  ligament  or  ligaments. 

The  cord  itself  differs  strikingly  from  the  brain  in  this  respect — 
that  its  gray  matter  is  its  inner  substance,  and  its  white  matter  its 
outer.  Its  white  cortex,  so  to  speak,  is  composed  of  conducting  fibers 
which  lie  immediately  beneath  its  envelop  of  pia  arachnoid.  Within 
the  gray  matter  lie  the  centers  for  reflex  action,  in  their  turn  presided 
over  by  the  higher  brain  centers,  which  send  their  messages  down 
through  the  fibers  of  the  white  matter  and  receive  messages  in  return. 
One  remembers  further  that  the  cord  is  divided  into  two  lateral  halves 
by  the  anterior  and  posterior  fissures;  that  the  posterior  (sensor}-) 
nerve-roots  enter  the  cord  on  either  side  near  the  posterior  fissure,  and 
form  the  posterior  lateral  fissures.  Analogous,  but  much  less  obvious, 
anterior  lateral  fissures  are  formed  by  the  emerging  anterior  (motor) 
nerve-roots.  The  gray  matter,  with  its  rough  H  shape,  comprises  much 
the  smaller  part  in  bulk  of  the  cord,  the  major  part  of  which  is  made  up 
of  the  white  ascending  and  descending  fibers  arranged  in  columns. 


ANATOMY    AND    rilYSlOl.UGY    OF   THE    COKD 


671 


These  arc  the  cohinins  which  the  ytudcnt 
would  fain  remember  accui-ately,  if  he  shall 
arrive  at  a  capacity  for  the  careful  diag- 
nosis of  cord  lesions.  Within  the  gray  VA  21^ 
matter,  in  the  midst  of  the  commissure, 
runs  the  central  canal  of  the  cord,  a  deep 
well,  which  drops  from  the  bottom  of  the 
fourth  ventricle  and  ends  blindly  at  the 
tip  of  the  cord  within  the  filum  terminale. 
This  central  canal  is  lined  with  a  continua- 
tion of  the  ventricular  ependyma,  and  is 
important  for  its  relation  to  spina  bifida 
and  syringomyelia. 

The  accompanying  figure,  taken  from 
Toldt,  wiir  recall  diagrammatically  to  the 
reader  the  structure  of  the  neurons,  those 
units  which  make  up  the  substance  and 
structure  of  spinal  nervous  elements.^ 

The  reader  will  observe  that  the  axones 
of  the  peripheral  nerves,  outside  the  spinal 
canal,  are  furnished  with  a  protective  neu- 
rilemma (sheath  of  Schw^ann),  while  the 
fibers  in  the  cord  substance  have  no  such 
sheath.  Where  the  sheath  does  not  exist, 
regeneration  of  a  damaged  nerve-fiber  does 
not  take  place ;  but  where  there  is  a  neuril- 
emma (Schwann),  the  nerves  regenerate 
eagerly.  In  surgical  practice,  therefore,  we 
observe  that  when  the  cord  (devoid  of  a 
neurilemma)  has  been  damaged  in  whole  or 
in  part,  there  results  a  permanent  loss  of 


M 


V 


.2    Rv 


iW 


Fig.  432. — Spinal  cord  connected  above  with 
the  medulla  oblongata  and  pons:  V,  Nervus  trigem- 
inus; XII,  nervus  hypoglossus ;  C,  first  cervical 
nerve;  C,  2-8,  second  to  eighth  cervical  nerves; 
T,  1-12,  first  to  twelfth  thoracic  nerves;  L,  1-15,  ,. 

first  to  fifth  lumbar  nerves;  S,  1-5,  first  to  fifth  <^ 
sacral  nerves;  6,  nervus  coccygeus;  xx,  filum  termi- 
nale; from  the  root,  marked  L  to  x,  corda  equina; 
Rr,  plexus  brachialis;  Cr,  ner\-us  femoralis;  Sc, 
nervus  ischiadicus;  O,  nervus  obturatorius.  The 
enlargements  opposite  L,  3,  4,  5,  represent  the 
spinal  ganglia  on  the  dorsal  roots.  On  the  left  side 
of  the  figure  the  sympathetic  trunk  is  shown:  A,  to 
SS,  ganglia;  o,  ganglion  cervicale  superius;  6c,  gan- 
glion cervicale  medium  and  inferius;  d,  first  thoracic 
ganglion;  d,  last  thoracic  ganglion;  1,  first  lumbar 
ganglion;  ss,  first  sacral  ganglion  (^rom  Rauber). 

1  J.  B.  Murphy,  Surgery,  Gynecology,  and  Ob- 
stetrics, April,  1907,  gives  an  admirable  practical 
review  of  this  subject. 


672 


THE    HEAD    AND    SPIXE 


sensory  and  motor  function  in  the  parts  below  the  damage.  There  is 
no  satisfactory  cvitlence  that  the  severed  cord  can  be  repaired  by  cither 
surgical  or  natural  means. 

Severed  or  damaged  peripheral  nerves  (with  sheath  of  Schwann), 
on  the  contrary,  ma}-  and  do  repair  themselves  by  natural  processes; 
may  be  repaired  surgically;    and  will  regain  function  completely. 

If  a  nerve  be  divided,  that  part  of  it  toward  which  impulses  travel 
will  degenerate.  In  motor  nerves  the  degeneration  takes  place  there- 
fore toward  the  periphery  of  the  body;  in  sensory  nerves,  toward  the 
center,  or  cord-ward;  but  degeneration  progresses  only  so  far  as  the 
immediate  axones  concerned,  and  does  not  attack  associated  axones. 


Fig.  4.33. — Showing  the  tracts  and  tlie  functions  of  various  tracts  of  spinal  cord 

(Butler). 


We  remember  always,  however,  that  peripheral  nerves  (neurilemmic) 
are  capable  of  repair  and  regeneration  for  months  after  their  damage — 
witness  the  astonishing  repair  and  functional  restoration  of  the  trifacial 
nerve — repair  which  may  take  place  long  after  the  nerve  has  been 
divided  for  trifacial  neuralgia. 

In  general  terms,  in  the  case  of  the  spinal  cord,  when  it  is  damaged 
or  interfered  with,  we  see  results  Cjuite  similar  to  those  which  follow 
like  damage  to  the  lirain.  ^^'c  knov\-  that  much  of  the  gravity  of  lesions 
within  the  skull  is  due  to  intracranial  pressure — that  the  brain  fills 
completely  a  closed  box,  and  that  the  slightest  addition  to  the  con- 
tents of  that  box  will  cause  an  increase  of  intracranial  tension.  The 
cases  of  the  spine  and  cord  are  similar,  though  in  the  case  of  the  spine, 


ANATOMY   AND    PHYSIOLOGY    OF  THE   CORD 


673 


the  box,  or  bony  tube,  is  less  tight  than  is  the  skull,  so  that  there  is 
some  room  for  slight  expansion  through  the  various  vertebral  foramina. 
Keverthelcss,  pressure  on  the  cord,  slight  pressure  even,  may  givQ  rise  to 
Bcrious  motor  and   sensor}'  s^nijitoms — general  symptoms  when  the 


Fig.  434. — Showing:  a,  Cross-section  of  spinal  cord  with  anterior  and  posterior 
roots  and  gangha;  h,  cross-section  of  nerve-trunk,  showing  the  perineural  and 
interfascicular  connective  tissue;  c,  motor  neuron;  d,  sensorj'  neuron  (Murphy). 

pressure  is  diffuse,  as  in  the  case  of  effusion  from  meningitis;  focal 
symptoms,  disturbances  in  limited  areas,  when  the  pressure  is  exerted 
on  particular  points  of  the  cord.  In  a  sense,  local  pressure  on  the  cord 
is  a  more  serious  matter  than  local  pressure  on  the  brain.     For  example. 


674  THE   HEAD    AND    SI'IXE 

an  intracranial  meningeal  tumor,  especially  if  located  over  a  "silent 
area,"  may  exist  for  months  or  years  without  producing  nuuked  dis- 
turbances; but  a  tumor  pressing  upon  the  cord  within  the  spinal  canal, 
inevitably  will  cause  serious  disturbances  or  loss  of  function  to  all 
parts  of  the  cortl  below  it.  There  are  no  silent  areas  in  the  cord.  Brain 
substance,  in  certain  areas,  may  be  lost  without  special  distress  follow- 
ing. Cord  substances  may  not  be  lost  without  permanent  distress 
following  its  loss. 

From  such  general  considerations  we  conclude,  therefore,  that  any 
increase  of  intraspinal  tension — from  inflammatory  exudates,  s3'ringo- 
myelia,  tumors,  bone  pressure  from  fracture  or  disease,  exostoses, 
tuberculomata,  and  sundry  other  lesions,  will  inevitably  result  in 
disturbances  to  the  cord's  'structure  or  function.  By  their  symptoms, 
we  shall  know  them;  though  the  elaborate  study  of  symptoms  would 
lead  us  far  into  the  field  of  neurology,  we  must  touch  upon  these  matters, 
and  consider  briefly  the  remedies  which  surgery  may  offer. 

CONCUSSION  AND  CONTUSION 

We  speak  of  concussion  of  the  spine  and  contusion  of  the  spine, 
and  we  find  that  the  terms  are  in  debate,  as  are  the  terms  concussion 
and  contusion  when  applied  to  the  brain.  More  than  thirty  years  ago 
the  term  "railway  spine"  was  introduced  by  Erichsen,^  who  meant  a 
symptom-complex — paralyses,  hyperesthesias,  and  similar  disturbances 
— which  follows  slight  injuries  to  the  back  and  disappears  eventually, 
leaving  the  patient  well.  Many  observers  to-day  prefer  to  describe 
these  disorders  as  traumatic  neuroses.  "  Concussion  of  the  spine"  seems 
justified  clinically,  and  may  be  regarded  as  a  temporary  reaction  on 
the  part  of  the  cord,  but  without  definite  morbid  changes.  Erichsen 
describes  the  following  case:  A  man  of  forty -four  was  thrown  from 
his  carriage,  and  received  no  obvious  external  injury.  A  day  or  two 
after  the  accident  he  observed  anesthesia  and  monoplegia  of  the  right 
arm,  followed  later  by  cervical  and  dorsal  pain  and  hyperesthesia  of 
the  left  arm.  Three  days  later  both  legs  became  paraplegic,  but  the 
sphincters  remained  unaffected.  He  recovered  gradually.  J.  B. 
Murphy  relates  a  similar  accident  in  the  case  of  a  woman,  who  died 
of  pneumonia  ten  days  after  the  injury.  No  changes  whatever  in  the 
brain  or  cord  were  found  at  the  autopsy. 

Contusions  of  the  spine  are  more  serious  affairs,  and  they  may  be 
of  varying  grades  of  severity — from  bruising  of  the  ligaments  and 
vertebral  processes  to  bruising  of  the  nervous  elements,  with  consequent 
paralyses,  but  without  division  of  the  axones.  Frequently  there  results 
an  escape  of  blood  into  the  spinal  canal  or  cord,  or  a  traumatic  zonal 
inflammation.  The  symptoms  of  such  damage  may  not  develop  for 
several  hours  or  days  even  after  the  injury;  and  they  present  us  with 
no  typical  clinical  picture  whatever.  There  may  result  pains  in  the 
extremities  or  back,  paralyses,  anesthesias  and  hyperesthesias,  involv- 
1  John  E.  Erichsen,  On  Concussion  of  the  Spine,  Nervous  Shock,  1875. 


WOUNDS   OF  THE   CORD  675 

ing  one  or  more  of  the  extremities.  Often  the  patient  is  completely 
crippled,  but  so  long  as  the  axones  are  not  divided,  restoration  of  func- 
tion is  possible,  through  the  resolution  and  absorption  of  exudates, 
and  the  resulting  relief  to  irritation  of  the  cord  and  nerve-roots.  Con- 
valescence is  extremely  tedious,  however,  and  may  require  months  or 
years.  Many  of  these  patients  may  be  greatly  helped  in  regaining 
the  use  of  their  limbs  by  a  course  of  careful,  systematic  training  and 
by  electric  stimulations. 

From  this  explanation  of  the  nature  of  cord  contusions,  as  they  are 
commonly  understood,  we  see  that  they  differ  essentially  from  many 
contusions  of  the  brain.  Contusion  of  the  brain  implies  generally  an 
actual  destruction  of  nervous  elements. 

WOUNDS  OF  THE  CORD 

Wounds  of  the  cord  are  far  more  serious  affairs  than  are  concus- 
sions or  contusions.  Wounds  of  the  cord  may  be  from  punctures  or 
from  crushing  forces, — by  a  bullet,  a  knife,  or  a  fracture  of  the  spinal 
column, — and  these  wounds  imply  an  actual  destruction  of  the  cord's 
elements.  Writers  point  out  that  a  majority  of  punctured  wounds  of 
the  cord  occur  in  the  cervical  and  upper  dorsal  regions,  for  an  assailant 
aims  to  damage  his  victim  in  the  head  or  the  thorax.  We  know  also 
that  knife  wounds  generally  sever  one-half  the  cord  only. 

Wounds  of  the  cord  are  extremely  serious  affairs,  for  the  axones 
once  divided  there,  never  regenerate. 

The  symptoms  appear  at  once  in  these  cases,  and  not  late,  as  after 
contusion.  At  least  a  quarter  of  the  patients  die;  many  improve,  but 
none  recover  completely. 

The  surgeon  can  do  little  for  these  cases.  He  cannot  restore  by 
suture  the  wounded  cord ;  a  laminectomy  is  almost  certain  to  increase 
the  existing  damage.  Laminectomy  may  be  necessary,  however,  to 
relieve  an  increasing  hemorrhage  which  aggravates  the  intraspinal 
pressure  and  makes  worse  the  symptoms  from  which  the  patient  is 
suffering.  One  should  not  perform  laminectomy,  however,  without 
doing  a  preliminary  lumbar  puncture;  and  lumbar  puncture  alone, 
which  establishes  the  diagnosis,  may  often  suffice  to  relieve  many  of 
the  paralytic  symptoms.  Then  a  bullet  or  a  bone  spicule  may  be  dis- 
covered by  the  a:-ray,  and  should  be  removed. 

The  hemorrhage  to  which  I  have  referred  may  be  distributed  vari- 
ously— it  may  be  extradural,  beneath  the  meninges,  or  in  the  substance 
of  the  cord  itself.  When  the  blood  lies  beneath  the  meninges,  the 
condition  is  called  hematorachis ;  when  within  the  substance  of  the 
cord,  it  is  called  hematomyelia. 

It  is  difficult  without  lumbar  puncture  to  make  a  diagnosis  of  these 
various  forms  of  hemorrhage.  The  nature  of  the  injury  may  suggest 
the  condition,  but  does  not  distinguish  between  hematorachis  and 
hematomyelia.  Yet  for  the  purposes  of  treatment  and  prognosis  one 
should  attempt  to  make  the  distinction.     The  patient  may  recover 


676  THE    HKAD    AND    SPIXE 

from  hemorrhage  beneath  the  meninges.  Hemorrhage  within  the 
substance  of  the  cord  results  in  permanent  but  ^•arying  paralyses. 
The  symptoms  of  hematorachis,  in  general  terms,  are  pain  in  the  spine, 
intermitting  and  burning;  pains  along  the  courses  of  the  nerves;  some- 
times muscular  spasms,  convulsions,  and  finally  paraplegia.  The  suc- 
cession of  these  s}'mptoms  suggests  closely  the  succession  of  symp- 
toms resulting  from  intracranial  hemorrhage — first,  a  stage  of  excite- 
ment; second,  a  stage  of  paralysis.  These  hemorrhagic  paraplegias 
are  of  gradual  onset  and  are  quite  different  from  the  sudden  and 
complete  paraplegias  which  follow  spinal  fractures.  The  slowly 
increasing  hemorrhage  may  not  result  in  paraplegia  for  two,  three, 
or  more  days.  Fortunately,  most  of  the  cases  of  hematorachis  recover 
spontaneously  in  from  one  to  two  months.  Hematomyelia,  hemorrhage 
into  the  substance  of  the  cord,  is  a  much  more  serious  affair,  as  I  have 
said,  especially  as  it  is  wont  to  occur  in  the  upper  regions  of  the  cord, 
with  resulting  paraplegia  of  all  the  parts  below,  depending  upon 
the  exact  site  and  location  of  the  effused  blood.  Hemorrhage  into  the 
gray  matter  only,  especialh-  when  high  in  the  cord,  is  recognized  by 
wasting  of  muscles  and  anesthesia  of  the  upper  limbs;  but  the  much 
more  common  hemorrhage,  involving  the  white  substance,  causes 
paraplegia  below  the  level  of  the  lesion.  The  outlook  for  all  these 
cases  of  hematomyeUa  is  extremely  doubtful.  Some  of  them  may 
recover  in  part,  but  always  with  a  resulting  weakness  due  to  the 
destruction  of  the  ganglion-cells  of  the  motor  neurons  at  the  point  of 
hemorrhage. 

DISLOCATIONS   AND  FRACTURES  OF  THE  VERTEBRA 

Dislocations  and  fractures  of  the  vertebrae  are  generally  associated 
the  one  with  the  other,  except  those  rather  common  dislocations  of 
the  atlas  on  the  axis,  which  frequently  occur  without  a  concurrent 
fracture.  Dislocations  and  fractures  of  the  vertebrae  in  general  pro- 
duce pressure  or  other  damage  of  the  cord  also,  with  resulting  nervous 
phenomena— except,  again,  in  the  case  of  atlas  dislocations,  which 
may  not  damage  the  cord.  In  all  cases,  however,  recovery  is  possible 
if  the  cord  be  not  wounded  and  if  pressure  be  relieved  timely. 

All  manner  of  violence  may  cause  vertebral  fractures  and  dislocations 
— violence  direct  and  indirect — crushing  blows,  forcible  flexions  of 
the  trunk  ("jack-knifing"),  and  falls  upon  the  feet  or  head.  The 
laminae  and  spinous  processes  may  be  broken  off  and  driven  into  the 
cord,  the  vertebral  bodies  may  be  crushed,  and  commonly  the  vertebral 
ligaments  are  torn,  so  that  one  or  more  of  the  vertebrae  are  forced  out 
of  place  (dislocation),  causing  pinching  of  the  cord. 

The  symptoms  and  signs  of  spinal  fracture  with  dislocation  are 
two-fold — anatomic  and  functional.  There  is  a  circumscribed  antero- 
posterior deformity,  often  with  obvious  crepitus;  and  if  the  cord  be 
compressed  or  severed,  there  ai-e  paralyses.  The  surgeon  is  especially 
concerned  with  estimating  the  extent  of  damage  to  the  cord,  for  on  his 


DISLOCATIONS   AND   FRACTURES    OF   THE    VERTEBRA  ()77 

ascertaining  the  fact  of  this  tlcpends  his  treatment  and  prognosis, 
Nevertheless,  there  are  surgeons  who  assert  that  the  spinal  canal  should 
be  opened  and  explored  in  every  case  of  fractured  spine,  for  no  man 
may  say  what  is  the  extent  of  existing  damage.  I  cannot  concur  in 
this  advice  for  invariable  operation,  because  I  am  convinced  that  cer- 
tain: cases  give  certain  evidence  that  the  cord  is  severed,  and  in  a  severed 
cord  repair  is  impossible. 

If  a  positive  diagnosis  alwaj^s  were  possible  before  operation,  we 
might  conveniently  divide  spinal  fractures  into  the  three  classes  which 
Harvey  Gushing  suggests;  but  he  himself  says  that  elements  of  error 
may  be  present  in  this  classification.  As  a  working  rule,  or  point  of 
departure,  however,  the  surgeon  may  well  have  in  mind  these  three 


Fig.  435. — Dislocation  of  atlas  on  axis.     Note  characteristic  tilting  of  the  head 
(Massachusetts  General  Hospital). 

types  of  cases,  so  as  not  blindly  and  in  routine  fashion  to  open  down 
upon  all  damaged  spines.  The  three  types  are:  (1)  Those  cases  in 
which  an  operation  is  contraindicated  because  it  can  do  no  good, 
and  may  increase  the  damage  already  done.  To  this  group  belong  the 
traumatic  hematomyelias,  recognizable  from  the  symptoms  alone,  with- 
out a  radiograph,  and,  to  a  certain  extent,  able  to  recover  by  natural 
processes.  (2)  Those  common  cases  of  fracture-dislocation  w^hich  are 
bej'ond  all  hope  of  cure  because  there  is  a  complete  transverse  lesion 
of  the  cord.  The  site  of  the  injury — above  the  first  lumbar  vertebra — 
and  the  total  bilateral  paralyses  render  these  cases  fairly  obvious. 
We  may  operate  and  do  no  harm;  but  we  can  do  no  good.  (3)  Cases 
of  slight  damage  to  the  cord, — short  of  complete  section, — with  symp- 


(578  THE   HEAD   AND   SPIXE 

toms  which  are  increased  or  perpetuated  by  pressure  from  a  foreign 
body,  such  as  a  fragment  of  bone.  In  these  cases  we  must  operate, 
but  operate  so  judiciously  as  not  to  increase  the  existing  damage. 

Diagnosis  is  by  no  means  always  easy,  and  in  an  obscure  case  a 
surgeon  may  persuade  himself  that  he  is  dealing  with  an  example  of 
group  (3);  while  Walton  is  frequently  quoted:  "We  have  no  symp- 
toms from  which  we  can  assert  from  the  outset  that  the  cord  is  crushed 
beyond  at  least  a  certain  degree  of  repair.  It  has  been  said  that  where 
there  is  complete  loss  of  sensation,  motion,  and  patellar  reflexes  the 
cord  is  completely  crushed,  and  consequently  recovery  cannot  be  ex- 
pected." I  know  of  no  case  in  which  these  signs  of  paralysis,  and 
the  abolition  of  reflexes,  has  not  proved  to  be  conclusive  of  total 
division  of  the  cord. 

In  group  (3),  however,  we  do  see  fracture  with  bmising,  contusion, 
or  partial  destruction  of  the  cord,  and  we  see  motor  or  sensory  parah'sis 
below  the  line  of  damage.  But  the  paralysis  is  rarely  immediate,  as  is 
the  paralysis  in  class  (2),  and  is  never  complete  and  annular  of  both 
sensation  and  motion.  From  these  irregularities  of  class  (3)  we 
conclude  that  certain  columns  of  the  cord  are  intact.  The  paralytic 
symptoms  come  on  after  hours  or  days,  are  preceded  by  a  zone  of 
hyperesthesia,  and  are  accompanied  by  abolished  reflexes  in  this  zone.^ 
The  motor  phenomena  will  be  present  if  the  anterior  columns  of  the 
cord  are  involved;  the  sensory  phenomena,  if  the  posterior  columns 
are  injured.  Observe  also  that  precisely  the  same  gradually  increasing 
symptoms  may  be  present  if  compression  of  the  cord  exists  without 
contusion.  We  cannot  differentiate  contusion  from  compression. 
We  see  then  that  we  must  operate  in  the  cases  of  group  (3)  as  I  have 
described  them  in  these  paragraphs.  We  must  not  operate  for  hemato- 
myelia  lest  we  make  a  bad  matter  worse;  we  must  not  operate  for 
complete  section  of  the  cord — for  we  shall  do  no  good — provided  we 
make  the  diagnosis  in  these  events. 

So  far,  our  arguments  have  applied  to  damage  to  those  parts  of 
the  spine  which  inclose  the  coi-d  proper;  but  a  quite  different  situa- 
tion exists  in  case  the  spine  is  fractured  below  the  twelfth  dorsal  verte- 
bra. In  that  case  we  may  have  the  paral^-ses  and  other  evidence  of 
total  section  of  the  cord,  but  it  is  not  the  cord  which  is  damaged.  It  is 
the  Cauda  equina — a  bundle  of  peripheral  nerves  whose  axones  are 
covered  by  neurilemma,  or  the  sheath  of  Schwann.  These  nerves 
within  the  spinal  canal,  after  division  and  suture,  will  regenerate. 
Their  function  may  return  completely.  The  cord,  which  is  devoid 
of  neurilemma,  cannot  by  natural  processes  or  by  operation  be  made 
to  regenerate.  W^e  must  operate,  therefore,  on  all  cases  of  lumbar 
fracture,  and  attempt  to  repair  by  suture  the  damaged  cauda  equina. 
These  lumbar  fractures,  even  if  unrepaired,  are  those  which  the  patients 
may  long  survive,  though  paralyzed. 

Fractures  of  the  spine,  therefore,  are  extremely  grave  affairs,  and 
their  mortality  is  high  at  best.     WTiy  do  the  patients  die?    and  how 

^  J.  B.  Murphy,  ibid. 


DISLOCATIONS   AND   FRACTURES   OF  THE   VERTEBRA  679 

may  life  be  prolonged  and  made  endurable,  even  though  recovery  be 
impossible? 

The  course  of  spinal  fracture-dislocation  leads  to  death  in  a  major- 
ity of  cases;  and  the  patients  die  from  a  variety  of  causes,  which  may 
be  sunmied  up  as  damage  to  essential  spinal-cord  centers.  Fractures 
high  in  the  cervical  region  may  kill  in  twenty-four  hours,  with  the 
patient  lethargic,  in  a  high  fever,  which  may  reach  106°  or  107°  F.  even. 
This  lethal  fevei-  is  due  to  the  destruction  of  the  center  of  temperature- 
control.  In  the  high  fractures  also  the  excursion  of  the  diaphragm 
will  be  halted  through  damage  to  the  phrenic  nerve  in  the  fourth  and 
fifth  cervical  region.  Upper  dorsal  fracture  causes  serious  disturbance 
to  the  abdominal  organs.  Peristalsis  is  paralyzed,  and  the  belly  may 
become  greatly  distended.  In  all  spinal  fractures  above  the  second 
lumbar,  control  of  the  sphincters  is  abolished;  and  the  loss  of  control 
may  occur  after  low  lumbar  fracture  also,  through  injury  to  the  cauda 
equina.  One  of  the  most  troublesome  and  disheartening  complica- 
tions in  all  these  fracture  cases  is  the  early  development  of  bed-sores, 
which  quickly  attain  great  size  and  a  foul  appearance,  owing  to  the 
degeneration  of  the  trophic  nerves  of  the  region.  One  sees  these  sores 
over  the  sacrum,  buttocks,  and  heels  especially.  Loss  of  control  of  the 
bladder  and  anus  is  equally  common.  Urine  is  retained;  the  bladder 
becomes  septic,  usually  from  catheterization,  and  an  ascending  infec- 
tion invades  the  kidneys,  causing  death. 

We  must  direct  our  treatment,  therefore,  especially  to  care  of 
the  back,  the  bladder,  and  the  bowels.  I  am  accustomed  to  place 
the  patient  on  a  large  Bradford  frame,  which  allows  of  easy  access  to  the 
strategic  points.  AYe  must  keep  the  back  clean  and  dry;  sponge  it 
frequently  with  alcohol  and  dust  it  with  toilet-powder.  We  must 
avoid  using  the  catheter,  so  far  as  we  may.  Preferably  we  may  allow 
the  bladder  to  overflow,  starting  the  stream  by  pressure  with  a  finger 
behind  the  prostate;  or  we  may  establish  at  once  suprapubic  drainage, 
as  Harvey  Cushing  advises.  Of  course,  aU  such  operations  as  supra- 
pubic cystostomy  are  painless  to  the  paralyzed  patient.  The  rectum 
should  be  cleaned  out  daily  with  an  enema  of  soap-suds.  The  nutrition 
of  the  patient  may  be  fairly  well  sustained  by  a  careful,  easily  digested 
diet. 

These  unfortunate  patients,  especially  those  with  low  dorsal  or 
lumbar  fractures,  may  live  many  months  or  years.  They  often  seem 
to  acquire  a  surprising  degree  of  patience  and  fortitude.  Indeed,  their 
sufferings  are  mainly  from  lassitude  and  ennui.  There  is  little  or  no 
physical  pain. 

In  spite  of  occasional  successful  operations  the  mortality  for  all 
cases  of  spinal  fracture  is  extremely  high ;  but  the  pessimist  even  must 
admit  that  operations  occasionally  have  cured  when  the  cord  has  not 
been  severed;  and  so  observing  the  gradual  onset  of  symptoms  in  our 
class  (3)  we  must  operate  to  remove  pressure.  Other  cases  of  sup- 
posed complete  destmction  of  the  cord  at  the  point  of  fracture,  later 
may  give  signs  of  returning  function,  showing  that  the  paralyses  were 


680  THE    HEAD    AND    SPINE 

due  to  other  concurrent  injuries  and  not  to  cruishinjE;  destruction  (to 
hemorrhage,  pressure).  In  some  of  these  cases  of  class  (3)  late  sec- 
ondary operations  have  served. 

SPINAL  MENINGITIS 

Inflammation  of  the  spinal  membranes  plays  no  such  important  part 
in  the  work  of  surgeons  as  does  cerebral  meningitis — inflammation  of  the 
membranes  of  the  brain.  Nevertheless,  suppurative  and  serous  menin- 
gites  do  occur  within  the  spinal  canal,  and  are  amenable  to  surgical 
treatment.  Epidemic  meningitis  (cerebrospinal  fever)  also  is  common. 
I  have  discussed  this  disease  in  the  chapter  on  the  Brain,  and  have 
pointed  out  how  lumbar  drainage  may  relieve  the  symptoms  and  lead 
to  a  cure.  At  the  time  of  this  writing,  however,  we  are  coming  to 
depend  mostly  upon  the  serum  therapy  of  Flexner. 

Suppurative  meningitis  results  from  wounds  of  the  spine  or  from 
extension  from  cerebral  meningitis.  The  symptovis  are  general  and 
local,  and  are  fairly  characteristic.  The  patient's  fever  nms  high. 
He  appears  intensely  septic,  and  his  course  to  death  is  generally  short. 
The  local  symptoms  are  due  to  pressure,  and  we  observe  rigidity  and 
retracted  head,  sometimes  convulsions  and  opisthotonos;  and  later, 
paralyses  due  to  degeneration  of  cord  centers.  Surgeons,  with  the 
increased  confidence  born  of  experience,  are  feeling  that  drainage 
operations  save  some  of  these  desperate  cases,  but  the  drainage  must 
be  established  early. 

We  may  operate  in  the  following  manner:  By  lumbar  puncture  we 
obtain  fluid  for  culture  and  the  making  of  a  diagnosis.  Through  this 
same  channel  we  may  establish  continuous  drainage,  though  frequent 
tappings  generally  will  suffice.  In  addition  we  may  arrange  for  through- 
and-through  drainage  from  the  fourth  ventricle  to  the  lumbar  opening, 
or  we  may  open  a  lateral  central  ventricle,  as  I  have  shown  in  the  last 
chapter.  Murphy's  description  of  sacral  drainage  is  admirable.^  ''The 
skin,  subcutaneous  tissue,  fat,  and  muscles  are  divided  until  the  sacral 
foramina  are  exposed.  With  the  bone-cutting  forceps,  one  blade  in 
the  sacral  canal,  the  lamina?  are  divided  on  either  side  until  the  sacral 
dura  is  exposed  at  the  third  body.  This  is  easily  accomplished.  The 
sacral  dura  bulges  very  conspicuously  in  the  field,  and  corresponds 
to  the  middle  of  the  third  sacral  body,  \\  inches  from  the  coccygeal 
tubercles  (or  lower  postero-intemal  tubercles  of  the  sacinim).  It 
(sacra  dura)  forms  quite  a  large  area  or  pouch,  which  is  called  the 
sacral  cerebrospinal  cistern.  Before  opening  the  cistern  it  is  advisable 
to  aspirate  the  blood  (in  the  field)  by  siphon,  so  as  to  have  a  clear  view. 
This  accomplished,  the  dural  sac  is  split  and  sufficient  cerebrospinal 
fluid  allowed  to  escape  to  relieve  tension.  At  this  step  the  region 
should  be  temporarily  abandoned,"  and  the  skull  opened  behind  the 
foramen  magnum  over  the  cerebellar  cistern.  This  allows  through- 
and-through  irrigation  to  the  sacrum.     If  the  foramen  of  Magendie  is 

1  Murphy,  ibid.,  p.  423. 


SPINA   BIFIDA 


C81 


closed,  a  V-shapcd  piece,  of  the  velum  can  readily  be  removed  with 
scissors,  establishing  a  direct  communication  from  the  fourth  ventricle 
to  the  subcerebellar  cistern.  Murphy  employs  this  operation  in  cases 
of  central  h}'drocephalus  also. 

Serous  meningitis  (meningitis  serosa)  may  lead  by  pressure  through 
a  chain  of  general  symptoms— delirium,  headache,  choked  disc,  paral- 
yses—to death;  but  without  any  considerable  fever  often.  Serous 
meningitis  may  be  relieved  or  promptly  cured  by  lumbar  puncture  and 
by  drainage. 

After  all  such  operations,  and,  indeed,  throughout  the  course  ot  any 
meningitis,  the  general  care  of  the  patient  is  of  the  greatest  importance. 
In  hospitals  we  often  see  elementary  precautions  grossly  neglected. 
Patients  should  be  kept  absolutely  quiet,  in  a  darkened  room,  remote 
from  a  noisy  ward.  Nurses  and  other  attendants  should  be  gentle  and 
speechless  for  the  most  part.  We  must  keep  up  a  good  ventilation; 
keep  the  patient  warm,  and  attend  scrupulously  to  the  proper  evacua- 
tion of  his  bladder  and  rectum.  Loud  talking,  rapid  footsteps,  drafts, 
strong  light,  rough  handling,  often  will  bring  on  needless  convulsions, 
which  exhaust  and  may  kill  even  the  patient.  Verbum  sapienh:  aU 
others  should  be  excluded  from  the  patient's  presence. 

SPINA  BIFroA 

Spina  bifida  is  a  common  abnormality  of  the  spine— a  deformity 
instantly  obvious,  as  a  rule.  It  may  be  associated  with  cephalocele, 
which  is  its  cranial  analogue.  "  This  congenital  defect  of  development 
(spina  bifida)  involves  a  cleft  or  defect  of  one  or  more  of  the  neural 
arches,  with  the  protrusion  of  a  hernia-like  sac  formed  by  some  of  the 
spinal  membranes,  with  or  without  the  cord  or  nerve-roots.  It  occurs 
about  once  in  1000  births"  (Woolsey).  . 

We  remember  that  the  cord  and  other  nerve  elements  are  derived 
from  the  ectoderm  through  infolding;  while  the  bony  envelop  of  the 
cord  comes  from  the  mesoderm.  If  this  mesodermic  stnicture  fails 
properly  to  unite  about  the  cord,  a  protmsion  of  the  cord  or  its  mem- 
branes may  occur— usually  toward  the  rear,  sometimes  toward  the 
front.  Generally  the  abnormal  window  in  the  bone  is  small,  so  that 
the  protruding  nervous  elements  resemble  a  hernia.  Rarely  the  whole 
of  the  bony  sheath  on  one  side  of  the  cord  may  be  absent. 

There  are  varieties  of  spina  bifid^e,  as  there  are  varieties  of  cephalo- 
cele. Of  spina  bifida  we  have:  (1)  Meningocele,  membranes  and  fluid 
only-rare;  (2)  meningomyelocele  (hydromyelia) ,  membranes,  fluid,  and 
cord,  including  the  cauda  equina;  (3)  syringomyelocele,^^  which  is  only 
a  special  form  of  meningomyelocele,  with  a  great  dilatation  ot  the  cen- 
tral canal  and  its  ependyma.  The  symptoms,  the  prognosis,  and,  above 
all,  the  possibilities  of  treatment  depend  upon  the  variety  of  spma  biticla 
with  which  one  is  dealing;  and  the  varieties  and  subvarieties  are  more 
numerous  than  the  three  terms  I  have  used  seem  to  indicate,  -boi 
1  Syrinx  (L.);  ovptyS,  a  fistula,  a  pipe,  a  syringe. 


682 


THE    HEAD    AND    SI'IXE 


fji^ir)  jr-»tr. 


example,  there  are  three  forms  of  memngocde:  (o)  That  simplest  form 
in  which  the  only  defect  is  in  the  bone.  The  skin,  membranes,  and 
cord  are  intact ;  and  the  tumor  we  see  is  composed  of  the  dura  alone, 
which  bulges  with  its  contained  fluid  through  the  bone  cleft.  (6) 
Another  form  of  meningocele  is  like  the  last,  except  that  the  arachnoid, 
as  well  as  the  dura,  bulges.  The  contained  fluid  is  subarachnoid,  (c) 
Quite  another  subvariety  of  meningocele  is  that  in  which  the  dura,  as 
well  as  the  bone,  is  cleft.  The  arachnoid,  with  its  fluid,  bulges  through 
this  opening;  but  the  skin,  the  pia,  and  the  cord  are  normal  and  intact. 
There  are  varieties  of  meningomyelocele  or  myelomeningocele — 
the  terms  are  interchangeable.     Obviously,  the  terms  signif}'  a  tumor 

containing  membranes  and  nervous 
elements.  It  is  not  possible  always 
to  distinguish  this  foi'm  from 
syringomyelocele.  ]\Iost  properly, 
the  condition  present  is  a  myelocele 
— a  deformity  characterized  by  a 
cleft  in  the  skin  itself,  an  opening 
in  the  posterior  bony  wall  of  the 
spinal  column  and  in  all  the  mem- 
branes, while  the  posterior  surface 
of  the  cord  itself  is  split  or  absent. 
Thus  the  central  canal  of  the  cord  is 
left  open  to  the  air.  The  spinal 
hernia  which  is  present  is  due  to 
collections  of  fluid  between  the  pia 
and  arachnoid  on  the  opposite 
side  of  the  cord,  anterior  to  the 
cord.  This  fluid,  collecting  in  large 
amounts,  causes  a  protnision  of 
nervous  elements.  The  protrusion 
or  tumor  is  not  covered  with  skin, 
therefore,  though  the  skin  sur- 
rounds its  base;  and  such  a  sac 
as  there  is  consists  of  pia  covered 
by  the  spread-out  substance  of  the 
cord.  Myelocele  does  not  necessarily  protrude.  Such  a  myelocele  as 
I  have  described  may  exist  potent ialh;,  and  for  lack  of  fluid  collected  in 
front  of  the  cord  there  may  be  no  actual  hernia,  while  the  interior  of  the 
corci  itself  will  be  found  to  lie  deep  in  its  normal  groove,  but  exposed 
to  the  air. 

Syringomyelocele,  sometimes  called  myelocystocele,  is  more  common 
than  mj'elocele.  In  syringomj-elocele  the  bony  wall  and  the  dura  are 
cleft,  but  the  arachnoid  and  pia  are  intact,  while  the  central  canal  of  the 
cord  is  distended  with  cerebrospinal  fluid.  There  results  a  hernia  com- 
posed of  skin,  arachnoid,  pia,  and  nervous  elements,  while  the  center  of 
the  mass  is  occupied  by  cerebrospinal  fluid.  The  nervous  elements 
are  spread  out  thinly  over  the  inside  of  the  .sac. 


Fig.  4.36. — Spina  bifida  (side  view). 


SPINA    BIFIDA 


683 


We  see  then  that  spina  bifida,  so  called,  is  a  general  term  which  des- 
ignates spinal  tumors  of  varying  character  and  gravity.  For  example, 
meningocele  may  give  rise  to  few  symptoms;  may  inconvenience  the 
patient  from  its  size  merely;  may  be  carried  through  many  years  of 
life,  and  may  be  threatening  only  from  its  liability  to  ulceration  and  rup- 
ture. Spinal  hernias  containing  nervous  elements,  on  the  other  hand, 
generally  cause  various  paralytic  symptoms — especially  paralyses  of 
the  bladder  and  rectum,  and  motor  and  sensory  disturbances  of  the 
legs.  Myeloceles  are  inoperable  and  are  early  fatal  from  septic  infec- 
tions. We  need  regard  them  as  surgical  curiosities  only,  for  they  are 
incurable.  They  are  commonly  associated  with  other  abnormalities 
also — defects  of  development,  such  as  hydrocephalus,  club-foot,  ex- 
trophy of  the  bladder,  etc. 

The  diagnosis  of  myelocele  is  easy  and  instant,  for  the  abnormality 
has  no  covering  of  skin;  but  it  is  not  always  so  easy  at  the  time  of  the 


Spina  bifida  (meningocele)  (Massachusetts  General  Hospital). 


infant's  birth  to  distinguish  meningocele  from  myelocystocele.  The 
differential  diagnosis  must  be  founded  on  the  absence  of  symptoms  in 
meningocele,  and  on  the  paralytic  conditions  in  myelocystocele. 

The  only  possible  effective  treatment  in  either  of  the  more  favorable 
forms  of  spina  bifida  (meningocele  and  myelocystocele)  is  by  some  form 
of  operation.  We  can,  however,  assure  the  child's  parents  that  menin- 
gocele is  not  necessarily  very  serious;  but  that  a  child  the  victim  of 
myelocystocele,  if  it  should  not  die  young,  will  continue  in  a  wretched, 
crippled  condition  only. 

Taking  all  forms  of  spina  bifida,  we  learn  from  statistics  that  their 
prognosis  is  bad,  for  ulceration  and  rupture,  followed  by  meningeal  in- 
fection, is  the  probable  outcome.  Sometimes  a  palliative  aspiration, 
repeated  as  seems  advisable,  will  postpone  the  inevitable  rupture. 
The  aspiration  should  be  done  through  the  base  of  the  tumor,  and 


684 


THE    HEAD    AND    SPINE 


the  needle  should  be  introduced   obliquely  where   the   coverings   are 
thickest. 

Operative  treatment  is  commonly  by  excision,  though  rarely  in- 
jection methods  are  still  used.  For  injections,  Morton's  fluid  has  been 
most  favorably  regarded — a  composition  containing  10  grains  of  iodin ; 
30  grains  of  potassium  iodid;  1  ounce  of  glycerin.  The  injection  is 
given  two  or  three  times  at  ten-day  intervals.  The  surgeon  withdraws 
first  an  ounce  or  more  of  cerebrospinal  fluid  and  then  injects  half  an 
ounce  of  Morton's  mixture,  in  the  hope  of  causing  adhesions  of  the  sac 
and  a  resulting  cui'e.  I  have  never  met  a  surgeon  who  had  any  enthu- 
siasm for  this  method. 


Fig.  438. — Spina  bifida,  showing  line  of  incision. 

Open  operations  show  a  reasonable  percentage  of  good  results, 
especially  in  the  cases  of  meningocele.  The  dangers  are  from  sepsis. 
We  must,  therefore,  operate  with  the  greatest  aseptic  care.  Often  the 
dissection  is  tedious  and  laborious.  I  have  employed  satisfactorily  the 
transverse,  crescentic  skin  incision,  incircling  the  base  of  the  tumor 
with  the  convexity  of  the  incision  downward  (Fig.  438). 

Thus  we  expose  the  sac,  and  reflect  the  skin-flap  upward  across 
the  tumor.  With  the  sac  laid  bare,  incise  it  longitudinally  and  expose 
its  contents.  If  nervous  elements  lie  disengaged  within  the  cavity, 
tuck  them  into  the  spinal  canal.  Nervous  elements  may  appear  closely 
adherent  to  the  inner  surface  of  the  sac,  bunched  mostly  in  the  middle 


TUMORS   OF   THE   SPINE  685 

line,  with  their  general  course  from  the  summit  to  the  base  of  the  sac, 
that  is,  parallel  with  the  incision.  Separate  the  adherent  nerves  from 
the  sac,  so  far  as  possible,  and  reduce  them,  with  as  much  of  the  sac  as 
cannot  be  separated  from  them,  hito  the  spinal  canal;  then  excise  the 
excess  of  sac  and  sew  up  the  wound,  stitching  the  stump  of  the  sac  with 
double  rows  of  chromic-gut  stitches.  Trim  off  redundant  skin  and  close 
the  wound  without  drainage,  tacking  the  skin-flaps  close  to  the  under- 
lying aponeurosis.  If  the  bon}'  opening  is  so  large  as  to  favor  a  recur- 
rence of  the  hernia,  it  is  well,  before  closing  the  skin  wound,  to  reduce  the 
size  of  the  opening  by  bringing  strips  of  aponeurosis  across  the  stump 
of  the  sac.  Some  surgeons  have  advocated  repairing  the  vertebral 
clefts  by  an  osteoplastic  operation,  taking  bone  from  the  crest  of  the 
ilium;  but  this  must  rarely  be  necessary. 

If  the  spina  bifida  is  a  pure  meningocele,  the  operation  is  rendered 
easier  by  the  absence  of  nervous  elements.  The  sac  of  a  simple  menin- 
gocele is  trimmed  away,  and  the  wound  closed  as  I  have  already  described. 

After  all  is  done,  the  surgeon  must  remember  that  the  outcome  is  in 
doubt  until  firm  union  has  been  established.  Unfortunately,  the  wound 
may  break  down  and  a  spinal  fistula  become  established,  with  its  attend- 
ant danger  of  infection.  If  it  be  established,  one  must  attempt  to  close 
it  through  a  reopening  of  the  wound. 

TUMORS  OF  THE  SPINE 

Tumors  of  the  spine  are  somewhat  analogous  to  tumors  of  the 
cranium,  for  we  have  in  the  spine — (a)  Spinal-column  tumors,  originat- 
ing in  the  bone  or  involving  the  spinal  column  from  a  tumor  elsewhere 
in  the  body;  (6)  meningeal  tumors,  extradural  and  intradural;  (c)  tumors 
of  the  cord  itself ;  (d)  tumors  of  the  nerve-roots,  cauda  equina,  and  conus 
medullaris.  All  these  tumors  may  be  grouped  obviously  as  benign  and 
malignant,  as  primary  and  secondary. 

Tumors  of  the  vertebrae  are  like  tumors  of  bone  elsewhere,  which  I 
describe  in  another  chapter.  Those  which  are  malignant  are  inoperable 
mostly,  and  cause  pressure  symptoms,  often  agonizing,  generally  lead- 
ing to  paralyses.  Their  diagnosis  i-ests  upon  such  focal  s^'mptoms  as  we 
have  already  considered.  Benign  tumors  of  the  vertebrae,  more  especi- 
ally exostoses,  are  operable  often,  and  their  removal  in  some  cases  has 
been  followed  by  brilliant  recoveries.  These  exostoses  and  other  benign 
tumors  of  the  bone  are  generally  limited  to  one  vertebra,  commonly  to 
the  body  of  the  vertebra,  and  cause  symptoms  b}'  local  pressure  upon 
the  cord  and  nerve-roots.  These  sj^mptoms  are  such  as  I  shaU  describe 
— pain,  anesthesia,  and  paralyses.  Their  course  is  slow,  but  even  so, 
from  their  symptoms  one  cannot  distinguish  them  from  some  of  the  small 
malignant  tumors  until  an  operation  or  an  autopsy  has  revealed  their 
true  nature. 

Myeloma  is  a  form  of  tumor  which  I  have  already  mentioned  in 
speaking  of  tumors  of  the  cranium.  It  is  composed  of  tissue  identical 
with  the  red  marrow  of  young  bone,  and  formerly  was  called  myeloid 


686  THK   HEAD    AND   SPINE 

sarcoma.  It  is  often  a  general  disease,  and  is  found  in  the  cancellous 
tissue  of  several  bones  in  the  same  individual,  especially  in  the  tibia,  the 
radius,  and  the  jaw  bones.  Bland-Sutton  states  that  he  has  never  seen 
a  myeloma  in  a  vertebra,  but  other  ^vriters  have  described  the  tumor  in 
that  location.  The  diagnosis  must  be  based  on  the  albumosuria,  or 
Bence-Jones'  reaction,  which  is  regarded  as  pathognomonic.  It  is 
almost  impossible  to  remove  a  myeloma. 

Other  tumors  of  the  bones  of  the  spine  are  sacrococcygeal  tumors, 
parasitic  tumors  or  teratomata — irregular  pendulous  masses  attached 
to  the  coccygeal  region.  They  are  composed  of  undifferentiated  tissue, 
and  often  contain  mdiments  of  the  skeleton  or  various  organs.  Some- 
times they  are  operable,  though  it  frequently  happens  that  their  removal 
may  involve  destmction  of  the  coccygeal  nerves.  Every  such  tumor 
must  be  studied  independently.  If  its  excision  should  involve  extreme 
paralyses,  the  surgeon  may  think  it  best  to  let  it  alone. 

Meningeal  tumors  are  found  both,  without  and  within  the  dura. 
The  extradural  tumors  are  of  many  varieties — fatty  tumors,  sarcomata, 
tuberculomata,  echinococci,  myxomata,  fibrosarcomata,  and  carcino- 
mata.  Meningeal  tumors  are  more  common  within  than  without  the 
dura.  WTiile  all  the  varieties  of  spinal  tumors  show  similar  symptoms, 
tumors  of  the  meninges  grow  slowly  so  that  the  compression  exerted 
upon  the  cord  is  gradual  and  it  is  continuous.  We  know  of  tumors 
which  have  caused  symptoms  for  four,  six,  or  eight  or  more  years  before 
the  diagnosis  of  tumor  has  been  made.  Since  extradural  tumors  are 
more  commonly  malignant  than  are  intradural  tumors,  they  kill  the 
patient  sooner.  But  intradural  tumors  have  been  found  in  greater 
numbers — in  the  relation  to  extradural  tumors  of  two  to  one.  Intradural 
tumors  also  are  the  more  commonly  encapsulated,  while  their  situation 
is  generally  on  the  posterior  or  lateral  aspect  of  the  cord.  The  greatest 
number  are  in  the  thoracic  region,  and  next  to  that,  in  the  cervical 
region.  Both  extra-  and  intradural  tumors  spring  commonly  from  the 
dura,  the  intradural  occasionally  from  the  arachnoid  or  the  nerve-roots. 
Usually  meningeal  tumors  are  single,  though  sarcomata,  neuromata, 
and  parasitic  tumors  may  be  multiple. 

Meningeal  tumors  cause  no  symptoms  until  they  are  large  enough 
to  press  upon  the  spinal  nerves  and  cord,  but  the  symptoms,  even  then, 
do  not  depend  so  much  upon  the  size  of  the  tumor  as  upon  its  location 
and  density.  Continued  pressure  upon  the  cord  leads  eventually  to 
marked  changes  in  that  structure — to  edema,  softening,  degeneration 
of  centrifugal  axones  below,  and  centripetal  axones  above,  the  point 
of  compression;  and  to  meningeal  hypertrophy.  As  IMurphy  states, 
however,  we  must  remember  that  the  conductivity  of  the  cord  persists, 
partially  at  least,  even  after  long-continued  pressure. 

The  symptoms  of  meningeal  tumors  are  for  long,  intricate,  and  mis- 
leading. The  disease  is  relatively  rare,  so  that  physicians  are  generally 
led  away  into  other  diagnoses — neuritis,  rheumatism,  tabes,  lead  cohc, 
sacro-iliac  disease,  and  such  abdominal  diseases  even  as  gall-bladder 
infection,  gastric  ulcer,  and  appendicitis.     And  yet,  the  symptomatology 


TUMORS   OF   THE   SPINE 


687 


Fig.  439. — Anterior  view  of  the  areas  of  distribution  of  the  sensorj^  nerves  of  the 
skin  (shown  on  the  left  side  of  the  body),  and  distribution  of  sensation  according  to 
segments  of  the  spinal  cord  (shown  on  the  right  side  of  the  body):  1,  Ophthalmic 
nerve;  2,  superior  maxillary  nerve;  3,  inferior  maxillary  ner\'e  (the  points  of  exit 
of  the  supra-orbital,  infra-orbital,  and  mental  nerves  are  shown  by  the  markings 
X);  4,  points  of  exit  of  the  anterior  intercostal  branches  of  the  intercostal  nerves; 
5,  points  of  exit  of  the  lateral  branches  of  the  intercostal  nerves;  6,  intercosto- 
humeral  nerve;  A.M.  and  S.C.,  area  of  distribution  of  the  great  auricular,  super- 
ficial cers'ical,  and  supraclavicular  branches  of  the  cervical  plexus;  C,  circvmiflex 
nerve;  W,  ners-e  of  Wrisberg;  I.C.,  internal  cutaneous  area;  M.S.,  musculo- 
spiral  area;  M.C.,  musculocutaneous  area;  U,  ulnar;  M,  median;  R,  radial; 
G.C.,  genitocrural  area  (the  nerve  is  seen  as  distributing  its  branches  to  the  genital 
region  and  to  the  upper  portion  of  the  thigh);  E.C.,  external  cutaneous  area;/./., 
iho-inguinal  area:  I.C.U.,  internal  cutaneous  area  of  the  thigh:  M.C.U.,  middle 
cutaneous  of  thigh;  I.S.,  internal  saphenous;  P,  external  popliteal  branches  area 
(on  the  right  side  the  division  according  to  segments  is  seen,  the  letters  C,  D,  L, 
and  S  standing  respectively  for  cervical,  dorsal,  lumbar,  and  sacral  segments  of  the 
cord.  On  the  right  side,  from  the  fourth  dorsal  to  the  twelfth  dorsal  (inclusive), 
the  maximum  points,  according  to  Head,  of  the  abdominal  viscera,  are  shown  in 
relation  to  the  spinal  segments)  (Eisendrath). 


688  THE    HEAD    AND    SPIN'E 

of  meninp;oal  tumors  seems  definite  enough  wlien  we  come  to  write  it 
down.  There  are  general  symptoms  and  special  topographic  symptoms; 
symptoms  of  sensation  and  symptoms  of  motion. 

The  important  sensory  symptoms  are  root  symptovjs — pain,  h\'per- 
esthesia,  and  anesthesia.  The  pain  may  be  accentuated  by  iiiitating 
the  cutaneous  part  corresponding  to  the  cord  segment  involved,  by 
percussion  and  by  movement.  The  pain  is  severe,  but  not  always 
constant;  it  is  unilateral  or  bilateral.  It  precedes  the  anesthesia  and 
the  motor  disturbances. 

The  77wtor  syinptoms  are  due  to  pressure  upon,  and  degenerative 
changes  in,  the  cord  itself — spasms,  muscular  atrophy,  reaction  of 
degeneration,  and  paralyses.  At  first  the  paralysis  may  be  limited  to 
one  limb,  or  it  may  be  of  the  Brown-Sequard  type  (paralysis  on  the 
side  of  the  lesion;  anesthesia  on  the  opposite  side,  owing  to  the  decussa- 
tion of  the  sensor}'  fibers  immediately  after  their  entrance  into  the 
spinal  cord).  An  extensive  tumor  may  involve  both  sides  of  the  cord 
and  cause  complete  paraplegia.  The  reflexes  are  increased  at  first  and 
are  then  abolished.  There  are  trophic  changes — herpes  zoster,  gloss}' 
skin,  decubitus.  There  are  vasomotor  disturbances,  and  there  are 
paralyses  of  the  sphincters.  Sometimes  the  spinal  column  appears 
fixed  at  the  site  of  the  tumor. 

Murphy  sums  up  the  symptoms  as  follows: 

(a)  Long-standing  neuralgia,  which  disappears  as  soon  as  the 
paralysis  of  motion  sets  in.  It  is  noticeable  even  then,  however,  when 
the  patient  sneezes  or  coughs. 

(6)  Gradual  loss  of  conductivity  of  impulses. 

(c)  Marked  spasticity  and  exaggerated  reflexes,  with  persistence  of 
complete  paraplegia  after  the  onset. 

id)  The  exaggeration  of  pressure  symptoms  due  to  local  compression 
without  sjDreading  the  pathologic  process  above  or  below  the  initial 
point  of  compression. 

(e)  Absence  of  a  tuberculous  taint;  a  good  general  health. 

It  is  not  easy  always  to  determine  precisely  the  site  of  the  tumor 
even  when  the  diagnosis  of  tumor  has  been  made.  One  must  be  familiar 
with  certain  topographic  facts  in  order  to  trace  local  symptoiyis  to  the 
exact  point  of  their  pathologic  causation.  One  must  know  the  exact 
relation  of  points  in  the  cord  to  their  corresponding  topographic  bony 
landmarks.  Observe  that,  as  a  rule,  the  level  of  the  sensory  paral- 
ysis is  nearly  on  a  level  with  the  involved  segment  of  the  cord. 
Nevertheless,  there  is  always  danger  of  estimating  the  site  of  the  tumor 
to  be  lower  than  it  actually  is.  One  should  look  for  the  tumor  at 
operation  not  at  the  upper  level  of  anesthesia,  but  two  vertebra)  above 
that  level.  The  reason  for  the  unexpectedly  high  level  of  the  tumor 
is  that  many  of  the  affected  dorsal  nerves  emerge  from  the  spine  and 
find  their  way  to  the  skin  at  a  point  somewhat  lower  than  the  tumor 
which  is  causing  their  degeneration.  Before  going  on  to  a  consideration 
of  the  treatment  of  these  meningeal  growths  we  must  study  briefly  those 
rarer  growths  which  spring  from  the  cord  itself. 


TUMORS   OF  THE    SPINE  689 

Intramedullary  Tumors. — These  tumors  again  may  be  likened  to 
brain  tumors.  'Jliey  ai'e  of  nuich  the  same  type,  and,  as  is  the  case  with 
brain  tumors,  they  are  far  less  common  than  meningeal  tumors.  In 
adults  the  most  common  cord  tumor  is  the  glioma.  The  next  most 
common  is  the  tuberculoma.  In  the  case  of  children,  on  the  other 
hand,  the  tuberculoma  is  the  more  common.  Sarcomata  and  myxo- 
mata  also  involve  the  cord,  but  are  usually  extensions  from  the  meninges 
or  from  the  spinal  nerve-roots.  Gliosarcomata  occasionally  develop  in 
the  cord,  and  are  generally  diffuse,  involving  the  entire  length  of  the 
cord,  including  the  medulla.  Syphilomata  and  angiogliomata  occasion- 
ally have  been  reported. 

The  symptoms  of  these  cord  tumors  are  similar  to  those  of  the  dural 
tumors,  but  the  pain  is  not  quite  so  severe.  Nevertheless,  it  is  generally 
impossible  to  differentiate  intramedullary  from  extrameclullary  growths. 
If  one  were  obliged  to  point  out  clinical  distinctions,  one  would  say 
that  with  intramedullary  growths  there  is  little  or  no  local  spinal  stiff- 
ness, and  that  movements  of  the  spine  do  not  increase  the  pain.  More- 
over, the  pain  frequently  is  not  in  the  spine  itself,  but  is  remotely  cutane- 
ous. Of  course,  there  are  atrophy  of  muscles,  paralyses,  and  the  re- 
action of  degeneration.  The  reflexes  are  at  first  exaggerated  and 
then  abolished ;  anesthesia  is  present  only  in  case  the  posterior  columns 
of  the  cord  are  affected,  while  the  usual  trophic  changes  are  found. 
True  cord  tumors  differ  also  from  meningeal  tumors  in  the  rapidity 
with  which  the}-  progress.  There  are  no  years  of  pain  preceding  para- 
plegia. In  other  words,  if  pain  be  absent  and  motor  disturbances  alone 
persist,  we  are  fairly  justified  in  assuming  that  the  tumor  is  intra- 
medullary. 

There  are  tumors  of  the  conus  medullaris  also  and  of  the  cauda 
equina.  Neurologists  have  come  to  believe  that  we  must  differentiate 
caudal  tumors  from  tumors  of  the  conus  because  tumors  of  the  cauda 
often  yield  to  surgical  treatment,  while  tumors  of  the  conus  do  not 
so  yield  as  a  rule.  Tumors  of  the  conus  cause  a  bilateral,  symmetric 
impairment  of  sensation — especially  anesthesia  of  the  skin  over  the 
penis,  scrotum,  perineum,  anus,  inner  aspect  of  the  buttocks,  and 
posterior  surfaces  of  the  thighs.  Late  in  the  disease  there  are  incontin- 
ence of  urine  and  feces,  loss  of  sexual  power,  and  the  usual  decubitus. 

Tumors  of  the  cauda  equina,  on  the  other  hand,  spring  from  nerve 
structures  of  the  peripheral  type.  Anatomically,  therefore,  caudal 
tumors  are  quite  other  than  cord  tumors,  but  clinically  one  may  not 
so  readily  distinguish  them.  The  caudal  nerves  are  neurilemmic; 
therefore  they  maj-  regenerate  after  damage;  but  they  are  bunched 
together  within  a  meningeal  sheath;  therefore  their  tumors  give  the 
symptoms  of  cord  tumors.  A  tumor  of  a  caudal  nei've  will  give  us  a 
clinical  picture  suggesting  a  tumor  of  that  section  of  the  cord  from 
which  the  nerve  has  sprung.  On  the  other  hand,  tumors  of  the  cauda 
may  reach  a  considerable  size  before  causing  pronounced  symptoms, 
for  the  caudal  nerves  lie  loose  in  a  comparatively  spacious  pouch,  so 
that  a  small  tumor  there  causes  no  pressure. 

44 


GOO  THE   HEAD    AND   SPINE 

We  are  told  that  trauma  is  a  common  cause  of  caudal  tumors,  but 
this  was  not  the  case  with  a  remarkable  tumor  which  killed  a  patient 
under  my  care  not  long  since.  She  was  a  young  married  woman,  five 
months  pregnant  with  her  first  baby  when  she  consulted  me  for  ex- 
cruciating but  intermittent  sciatic  and  sacral  pains.  1  was  unable  to 
make  a  diagnosis;  but  supposed  for  a  time  that  she  suffered  from  that 
form  of  sacro-iliac  damage  common  with  puerperal  women.  A  well- 
known  orthopedic  surgeon  agreed  with  me,  and  applied  various  pelvic 
and  lumbar  supports,  which  relieved  the  patient  for  a  time.  Then 
there  followed  in  three  months  more  pains,  anesthesia,  paralyses,  in- 
continence of  the  sphincters,  headache,  nausea,  choked  disk,  delirium, 
and  death.  A  month  before  she  died  she  gave  birth  to  a  premature 
infant  after  an  absolutely  painless  labor.  During  the  latter  weeks 
of  her  life  she  was  seen  by  a  number  of  other  consultants— obstetricians, 
internists,  neurologists— whose  diagnoses  varied  all  the  way  from  neu- 
rosis to  transverse  myelitis;  and  at  the  autopsy  we  found  a  sarcoma 
obviously  springing  from  the  cauda,  destroying  the  lumbar  cord,  in- 
vading the  whole  cord  as  far  as  the  cervical  region,  choking  the  spinal 
canal,  and  leading  to  a  hydrocephalus,  with  the  resulting  intracranial 
pressure  S3^mptoms  which  I  have  mentioned.^  No  case  could  illustrate 
better  the  difficulties  of  diagnosis  and  the  uselessness  of  operation 
in  a  rapidly  growing  caudal  tumor  spreading  by  continuity  to  the  cord 
itself. 

On  the  other  hand,  caudal  tumors  may  be  secondaiy  to  meningeal, 
brain,  and  cord  tumors  disseminated  through  the  cerebrospinal  fluid. 

The  symptoms  of  typical  caudal  tumors  are:  Pain,  sacral  and 
sciatic — "  a  more  wide-spread  pain  than  the  pain  of  cord  tumors,"  if 
only  one  might  distinguish.  The  pain  is  increased  by  movements  of 
the  legs.  Next  there  are  a  progressive  sensory  paralysis  of  the  perineum, 
anus,  buttocks,  and  genitalia,  and  paralysis  of  the  bladder,  rectum,  and 
legs.  As  in  the  case  of  cord  tumors,  the  reflexes  are  at  first  increased, 
then  diminished,  and  finally  lost.  Other  lesions  of  the  lumbosacral 
region,  especially  sacral  tuberculosis,  must  be  differentiated.  The  one 
leading  and  most  conspicuous  symptom  of  early  caudal  disease  is  pain. 

The  treatment  of  cord  timiors  and  of  tumors  of  the  meninges, 
conus  meduUaris,  ami  cauda  equina  is  the  least  difficult  part  of  our 
problem,  when  once  an  understanding  of  spinal  tumor  has  been  reached. 
To  be  sure,  the  subject  is  relatively  new,  and  surgeons  are  too  apt  to 
rely  on  the  directions  of  neurologists — not  working  with  them,  but 
under  them.  However,  for  the  surgeon  acquainted  with  the  leading 
features  of  spinal  diseases  the  mere  operating  seldom  presents  serious 
difficulties.  Before  operating,  it  is  well  to  try  a  short  course  of  anti- 
syphilitic  treatment,  for  under  such  treatment  most  unexpected  cures 
sometimes  are  achieved.  Four  weeks  should  be  the  maximum  of  such 
treatment  if  there  be  no  improvement.  One  should  endeavor  also 
to  eliminate  the  chance  of  tuberculosis  being  present  before  operating; 

1  This  case  is  admirably  reported  by  E.  W.  Taylor,  Boston  Med.  and  Surg.  Jour., 
February  7,  1907. 


TUMORS   OF  THE    SI'IXE  691 

and  in  case  a  neoplasm  is  reasonably  demonstrable,  one  should  de- 
termine, if  possible,  its  character  and  the  question  of  there  being  two 
or  more  such  grcnvths. 

In  estimating  diagnostic  points  and  planning  an  operation  one  should 
have  clearly  in  mind  certain  relations  which  exist  between  the  spinal 
cord,  the  points  of  emergence  of  the  nerves,  and  the  spinous  processes. 
1  have  already  indicated  these  relations.  Binnie,  in  his  admirable 
manual,  quoting  Chipault,  gives  the  following  rules: 

"  It  is  important  to  recognize  certain  easily  remembered  relations 
which  exist  between  the  spinal  cord  and  the  spinous  processes.  These 
relations  are  thus  described  by  Chipault : 

"  (a)  The  terminal  culdesac  of  the  dura  mater  corresponds  to  the 
fifth  lumbar  interspinous  space. 

"  (b)  The  inferior  limit  of  the  spinal  cord  is  situated  in  men  at  the 
level  of  the  first,  in  women,  of  the  second,  in  infants,  of  the  third,  lumbar 
spinous  process. 

"  (c)  The  cervical  segment  of  the  cord  terminates  at  the  level  of 
the  sixth  cervical  interspinous  space;  the  dorsal,  at  the  ninth  dorsal; 
the  lumbar,  at  the  inferior  border  of  the  twelfth  dorsal  spine;  Ihe 
sacral  segment  ends  at  the  superior  border  of  the  first  lumbar  spine. 

''  (d)  The  relations  of  the  summits  of  the  spinous  processes  to  the 
nerve-roots  ma}'  be  expressed  by  a  simple  formula  -VAhich,  while  not 
mathematically  correct,  is  sufficiently  so  to  act  as  a  guide  in  surgical 
intervention. 

"  For  adults,  the  formula  is:  In  the  cervical  region  to  find  the  nerve 
which  emerges  at  the  level  of  any  individual  spinous  process,  add  the 
numeral  one  to  the  number  of  the  process,  e.  g.,  it  is  the  third  cervical 
root  which  emerges  opposite  the  second  spinous  process.  In  the 
superior  dorsal  region  add  the  numeral  tuo  to  the  number  of  the 
process.  From  the  sixth  to  the  eleventh  dorsal  processes  add  the 
numeral  three.  The  inferior  part  of  the  eleventh  dorsal  spinous  process 
and  the  subjacent  interspace  corresponds  to  the  origin  of  the  sacral 
nerves." 

Laminectomy  is  the  operation  which  gives  the  surgeon  access  to 
the  spinal  canal  and  cord.  In  cases  of  vertebral  damage  by  trauma, 
laminectomy  is  our  frequent  resort.  Laminectomy  is  analogous  to 
operations  for  opening  the  cranium,  and  has  thus  further  similarity  to 
such  operations  on  the  skull  that  the  defect  produced  in  the  spine  is 
relatively  harmless  in  itself  and  need  not  be  repaired.  Laminectomy 
does  not  greatly  weaken  the  spinal  column,  for  the  strength  of  the 
spine  lies  in  the  bodies  of  the  vertebrae.  Sundry  methods  of  lamiaec- 
tomy  are  advocated.  All  cf  them  call  for  care  in  order  that  nerves, 
nerve-roots,  meninges,  or  cord  be  not  damaged;  but  with  any  reason- 
able caution  the  following  simple  operation  may  be  performed  readily 
by  the  surgeon  who  knows  the  use  of  his  tools  and  is  famihar  with 
human  anatomy.^ 

1 1  know  a  surgeon  of  considerable  experience  who  mistook  the  intact  dura 
for  the  cord  after  he  had  opened  the  spinal  canal. 


692 


THE    IIKAI)    AXD    SPIXE 


Make  a  deep,  liberal.  \'citical  cut,  five  or  six  inches  long,  directly 
down  upon  the  spinous  processes;  then  convert  this  straijiht  line  into 
an  H  by  making  two  .short  transverse  cuts  at  either  end  of  it.  Thu.s 
one  is  enabled  to  turn  back  freely  the  skin-flaps. 

With  the  knife,  and  by  blunt  dis.section,  scrape  back  the  muscles 
from  the  spinous  processes  and  lamina;,  first  on  one  side  thoroughly, 


Fig.  440. — Cersical  laminectomy:  A,  A,  Saw-cuts  through  the  laminse,  just 
within  their  junction  with  the  articular  process;  B,  Doyen  saw  in  act  of  dividing 
the  lamina>  at  a  right  angle  to  their  surface,  its  guard  (determining  the  de|)th  of  sec- 
tion) being  entirely  raised  at  the  beginning  of  the  division;  C,  knife  dividing  the 
ligamenta  subflava;  D,  osteotome  levering  away  the  muscles  of  the  vertebral  grooves, 
using  the  spinous  processes  as  fulcra  (Bickham). 

and  then  on  the  other.  There  is  sharp  bleeding  generally.  Check  it 
by  firm  packing.  Before  going  further  see  that  the  bones  are  widely 
exposed  and  that  all  bleeding  is  stopped.  The  steps  so  far  are  tedious 
and  often  laborious. 

Entering  through  the  bones  of  the  canal  is  not  difficult.  Divide 
the  interspinous  ligament  at  the  bottom  of  the  proposed  bone  window, 
remove  with  rongeur  forceps  all  the  spinous  processes  in  view,  and 


TUMORS   OF  THE   SPINE  693 

cut  aw;iy  part  ot  the  lowest  lamina,.     Then,  with  stout  cutting  forceps 

1 


A 


Fig.  441. — Osteoplastic  resection  of  the  spine:  A,  Tenaculum  forceps  holding 
back  composite  flap;  B,  B,  delicate  forceps  grasping  and  elevating  membranes  and 
forming  a  transverse  ridge;  C,  C,  tenacula  holding  apart  edges  of  incised  membranes; 
D,  angular  scissors  used  in  incising  membranes;  E,  half-button  of  bone  bitten  out 
of  lower  margin  of  last  lamina  in  flap  by  rongeur  forceps;  F,  similar  half -button 
bitten  out  of  upper  margin  of  next  stationary  lamina  below,  the  two  half-buttons 
forming  a  circular  opening,  when  in  contact,  for  drainage;  G,  vascular  fatty  areolar 
tissue  covering  membranes.  The  stump  of  the  excised  spine  is  sho's^^l,  in  impression, 
through  the  turned-back  flap  (drawn  from  cadaveric  operation)   (Bickham). 

(or  with  chisel,  osteotome,  or  saw),  cut  away  a  suitable  number  of 
laminae  on  either  side,  and  remove  the  excised  sections  of  bone. 


694  THE    HEAD    AXD    SPINE 

Now  we  have  the  dura  exposed  and  may  see  the  nerves  emerging 
from  it.  The  remainder  of  the  operation  is  obvious  enough,  and  its 
exact  nature  depends  upon  our  purpose  in  opening  tlie  spinal  canal. 
We  elevate  or  remove  bone  fragments,  open  the  dura,  inspect  the 
cord,  see  to  our  hemostasis,  excise,  if  necessary,  painful  nerve-roots 
and  tumors  (suture  the  severed  cord  if  we  hold  to  the  strength  of  an 
erroneous  conviction) ,  and,  al)ove  all  things,  provide  adequate  drainage, 
lest  operative  blood  and  clots  pressing  on  the  cord  leave  our  patient's 
last  state  worse  than  his  first. 

In  all  this  we  must  handle  the  nerves,  dura,  and  cord  with  such  care 
as  to  avoid  the  common  and  needless  bruising,  and  we  must  repair 
with  fine  gut  stitches  our  operative  rent  in  the  dura. 

The  closure  of  the  wound  and  the  dressings  are  commonplace 
matters,  but  in  the  after-treatment  we  must  observe  the  same  solicitude 
that  I  have  enjoined  for  the  care  of  fracture-dislocations  of  the  spine. 

Several  experienced  surgeons  make  a  bone-flap  through  a  U- 
shaped  incision  in  the  skin  and  replace  the  flap  m  toto.  I  have  no 
personal  experience  with  this  method. 

The  results  of  laminectomy  for  intraspinal  tumors  are  encouraging. 
Pain  is  relieved,  and  if  the  aneurilemmic  fibers  of  the  cord  be  not  de- 
generated, function  returns  in  greater  or  less  degree.  Tumors  may 
recur,  to  be  sure,  but  sarcomata  even  are  less  lial^le  to  recur  than  sar- 
comata elsewhere.  The  mortality  (from  meningitis  and  shock)  is  not 
much  above  10  per  cent.;  and  at  the  worst  we  may  feel  assured  that 
death  is  inevitable  without  operation.  We  are  justified  in  asserting 
that  here  is  a  branch  of  neurologic  surgery  already  successful  and  full 
of  promise. 

The  Peripheral  Nerves 

The  surgery  of  the  peripheral  nerves  is  a  subject  comparatively 
recent — much  more  recent  than  is  the  surgery  of  the  head  and  spine. 
Until  the  development  of  aseptic  surgery,  physicians  thought  that 
nerves  did  not  lend  themselves  to  surgical  treatment  so  far  as  any 
power  of  regeneration  in  them  was  concerned.  Modem  studies  teach 
us,  however,  that  neurilemmic  (peripheral)  nerves  are  capable  of 
regeneration  and  may  be  sutured  and  grafted  with  excellent  prospect 
of  restoration  of  their  function.  I  have  already  in  this  chapter  referred 
briefly  to  this  matter. 

The  manner  of  restoration  of  the  structure  and  function  in  the 
distal  portion  of  a  severed  peripheral  nerve  is  still  a  subject  of  active 
controversy.  We  know  that  after  the  division  of  a  peripheral  nerve 
the  distal  portion  regains  its  function  even  though  it  has  been  separated 
and  isolated  from  its  proximal  portion  for  many  months.  Neurolo- 
gists are  not  in  accord  as  to  the  nature  of  this  regeneration.  There  is 
the  "central  theor}',"  and  there  is  the  "peripheral  theory."  The 
"  central  theory,"  based  on  the  teaching  of  Waller,  hangs  upon  the 
neuron  doctrine — on  the  conception  of  the  entity  of  the  neuron — that 
is  to  say,  of  the  nerve  ganglion  with  its  dendrites  and  single  axone,  or 


NEURITIS  695 

peripheral  nerve  filament.  If  this  axone  be  anywhere  divided,  the 
"central  theory"  teaches  that  the  distal  isolated  segment  degenerates 
and  cannot  be  restored  to  structure  and  function  until  it  has  reunited 
with  the  living  proximal  portion  of  the  axone.  The  "  peripheral 
theory, "  maintained  especially  by  Albrccht  Bethe  and  by  Ballance 
and  Stewart,  appears  to  demonstrate  that  after  section  of  the  axone, 
although  degeneration  in  the  distal  portion  does  take  place,  neverthe- 
less, regeneration  occurs  in  the  same  distal  portion  without,  and  in- 
dependently of,  a  reunion  with  the  proximal  portion  of  the  divided 
axone.  At  the  same  time  function  in  the  distal  parts  is  not  restored 
until  the  severed  parts  are  reunited.  As  Woolsey  truly  remarks:  "  Two 
clinical  facts,  the  lack  of  regeneration,  after  division,  of  the  axis-cylin- 
ders of  the  spinal  cord,  which  have  no  neurilemma  or  neurilemma  cells, 
and  the  very  rapid  return  of  sensation,  after  secondary  suture,  support 
the  theory  of  peripheral  regeneration."  We  may  not  discuss  further 
this  intensely  interesting  subject,  though,  as  surgeons,  it  concerns  us 
nearly,  but  we  observe  the  fundamental  fact  that  whatever  the  theory 
of  regeneration,  certain  it  is  that  divided  neurilemmic  nerves,  when 
properly  approximated,  do  regain  their  histologic  structure  and  their 
function. 

There  are  three  leading  purposes  in  the  surgery  of  the  peripheral 
nerves.  We  operate  for  the  relief  of  pain,  by  section;  for  the  repair 
of  nerve  injury,  by  suture  and  by  anastomosis;  and  for  the  relief  of 
palsy  by  nerve  transplantation.  Let  us  now  consider  in  some  detail 
these  three  topics  and  the  sui'gical  measures  at  our  command. 

NEURITIS 

Neuritis  is  a  common  cause  of  the  pain,  for  which  we  may  be  forced 
to  cut  a  nerve.  The  term  neuritis  is  generally  taken  to  signify  inflam- 
mation of  a  nerve.  It  is  usually  an  inflammation  of  the  endoneurium, 
perineurium,  or  epineurium,  which,  through  thickening  and  swelling, 
constricts  the  axones.  Perineuritis  is  the  accepted  term,  and  the  disease 
in  this  form  is  generally  confined  to  a  single  nerve-trunk.  Multiple 
neuritis,  a  painful  affection  of  many  peripheral  nerves,  is  a  degenera- 
tion of  the  nerve-fibers  themselves  rather  than  an  inflammation.  Mul- 
tiple peripheral  neuritis  commonly  runs  a  self-limited  course,  and  does 
not  especially  concern  the  surgeon,  who  has  to  deal  rather  with  "  local- 
ized" or  "  simple"  neuritis. 

Simple  neuritis  arises  from  nerve  injuries,  wound  infections,  callus- 
formations,  the  pressure  of  new-growths ;  or  it  is  due  to  such  chemical 
poisons  as  alcohol  and  ether^  as  well  as  to  exposure  to  cold;  or  it  may 
arise  as  the  sequel  of  some  general  infectious  disease.  The  damage 
to  the  nerve  may  be  strictly  localized  or  may  spread  along  throughout 
the  nerve's  course.  Although  the  inflammation  is  acute  and  violent 
at  the  outset,  the  active  symptoms  may  subside  quickly  and  be  followed 
by  a  long-continued  chronic  course,  with  hyperplasia  of  the  connective 
tissue,  causing  more  or  less  destruction  of  nerve-fibers. 


696 


THE    HEAD    AND    Sl'INE 


The  symptoms  of  the  patient  vary  greatly,  but  always  there  is 
marked  perversion  of  function,  ranging  from  hyperesthesia  to  com- 
plete anesthesia.  The  pain  is  often  severe, — stabbing,  boring,  or  shoot- 
ing,— and  is  in  the  course  of  the  affected  nerve.  It  is  worse  at  night 
than  in  the  day,  and  is  aggravated  by  movements.  Tenderness 
also  develops  along  the  course  of  the  nerve.  There  is  frequent  numb- 
ness, with  tingling  and  loss  of  tactile  sensation.  There  may  be  weak- 
ness or  even  paralysis  of  the  motor  nerve-fibers,  with  preceding  twitch- 
ings  and  spasms. 

Sometimes,  if  the  neuritis  ])e  long  continued,  seiious  secondary 
changes — structural  and  trophic — occur  in  the  adjacent   parts — mus- 


I'ifi.  442. — Xerve-stretching. 

cular  atrophy;  contractures;  nail  ridges  with  nail  thickenings;  an 
atrophic,  glossy,  thickened  skin;  alterations  in  the  sweat-glands;  herpes, 
ulcerations,  and  gangrene  even.  Perforating  ulcer  of  the  foot  (mal 
perforans)  may  follow  neuritis  of  the  tibial  nerves.  There  are  changes 
too  in  the  electric  excitability  of  the  nerves,  and  the  reaction  of  degenera- 
tion results. 

As  a  rule,  the  prognosis  in  acute  neuritis  is  good;  and  after  months 
even  we  may  look  for  recovery. 

As  for  treatment,  the  surgeon  has  slight  concern  for  that  until 
called  upon  by  the  neurologist,  whose  non-operative  measures  have 


NEURALGIA  697 

failed;  but  in  advanced  cases  especially— those  cases  characterized 
by  trophic  changes,  by  gangrene  and  ulceration— nerve-stretching  has 
been  of  marked  value.  Indeed,  certain  surgeons  have  carried  still 
further  the  principle  of  nerve-stretching,  and  have  shown  this  measure 
to  be  of  service  in  cases  of  varicose  ulcer,  Raynaud's  disease,  and  many 
other  neurotrophic  conditions.  The  technic  of  nerve-stretching  is 
simple :  lay  bare  and  isolate  the  nerve-trunk  which  supphes  the  affected 
part.  Then  take  the  nerve  on  your  fingers  and  stretch  it  vigorously 
by  pulling  it  up  (Fig.  442) .  One  may  put  many  pounds  of  pull  upon  a 
nerve-trunk  without  breaking  it.  Experimental  researches  show  that 
the  nerve  is  traumatized — axis-cylinders  and  myelin — and  that  degen- 
erative changes  follow\  Gradually  the  later,  regeneration  takes  place. 
Meantime  we  expect  to  see  improvement  in  the  lesions  for  which  the 
nerve-stretching  is  employed. 

NEURALGIA 

Neuralgia  is  an  inadequate  term  for  which  we  have  as  yet  found  no 
substitute.  It  means  pain  in  the  course  of  a  nerve.  Neuritis  may  be 
the  cause  of  the  pain,  or  the  cause  may  be  some  constitutional  disease 
(gout,  syphilis),  or  a  local  lesion  like  mastoiditis  or  a  tumor;  or  there 
may  be  any  one  of  a  hundred  similar  causes.  The  neuritis  causing  a 
neuralgia  may  be  Hmited  and  superficial,  or  it  may  involve  the  whole  of 
a  nerve-trunk  and  its  associated  gangha.    ■ 

Neuralgic  pains  are  fairly  characteristic.  They  are  sharp,  stabbing, 
boring,  or  burning,  of  varying  intensity,  and  occur  in  paroxysms. 
They  may  be  mild,  or  they  may  be  so  persistent  and  excruciating  as  to 
tempt  the  victim  to  suicide.  The  pain  may  linger  dully  between  the 
paroxysms,  or  it  may  disappear  entirely.  Its  onset  is  uniform:  it  ap- 
pears at  the  accustomed  spot  and  follows  the  accustomed  course.  Some- 
times it  becomes  diffused,  to  the  confusion  of  the  patient  and  the 
physician.  Do  not  mistake  the  characteristic,  localized  pain  of  a 
neuralgia  for  those  simulated,  bastard  pains  of  which  the  hysteric 
complains. 

Victims  of  serious  neuralgias,  if  unrelieved,  go  on  to  a  life  of  con- 
stant and  hopeless  distress,  and  become  slaves  to  drug  habits.  ^  Then- 
general  health  becomes  seriously  impaired,  and  they  fall  victims  in 
turn  readily,  and  cheerfully  often,  to  other  chance  diseases. 

We  treat  neuralgia  by  drugs,  by  hygiene,  by  hydrotherapy,  by 
electricity,  and  similar  measures,  and  in  most  cases  we  succeed  in  curing 
the  ailment.  Some  few^  cases,  how^ever,  resist  such  endeavors,  and  we 
find  ourselves  driven  to  surgical  operations.  These  operations  include 
some  of  the  most  difficult  and  hazardous  measures  known  to  therapeu- 
tics. Let  us  take  up  in  brief  detail  certain  forms  of  neuralgia  and  their 
treatment  by  surgical  means. 

Trigeminal  neuralgia,  or  neuralgia  of  the  fifth  cranial  nerve,  is 
common,  but  the  cases  vary  greatly  in  severity.  The  mild  cases  are 
easily  cared  for;  the  severe  cases  demand  operations  of  the  first  magni- 


G98  THE    HEAD    AXD    SPINE 

tude.  Accordingly,  we  divide  the  disease  into  sundry  types,  and 
refer  to  these  types  as — (1)  Neuralgia  minor — a  mild  affection  in  which 
one  branch  only  of  the  nerve  is  affected;  (2)  reflex  neuralgia,  or 
visceral  referred  pain;   and  (3)  neuralgia  major,  or  tic  douloureux. 

Let  us  deal  biiefly  with  those  first  two  forms.  Neuralgia  minor 
occurs  commonly  in  neurotic  girls  and  young  women,  and  may  be  due 
to  a  variety  of  debihtating  causes.  Any  anemia  is  apt  to  be  associated 
with  this  form  of  neuralgia  or  tic.  The  reflex  neuralgias,  on  the  other 
hand,  are  due  to  some  true  anatomic  lesion — ulcer,  tumor,  carious 
teeth,  astigmatism,  ear  disease,  etc. — which  gives  rise  to  an  irritation  in 
the  neighboring  trifacial  nerve. 

The  syfnptoms  of  both  neuralgia  minor  and  reflex  neuralgia  (tri- 
geminal) are  quite  similar,  and  the  leading  symptom  is  pain — pain 
confined  commonly  to  one  branch  of  the  nerve.  The  pain  is  usually 
intermittent;  it  follows  the  course  of  the  nerve,  and  is  associated  with 
tenderness  of  the  surrounding  skin — tenderness  which  often  remains 
after  the  actual  neuralgic  pain  has  subsided.  Sometimes,  but  not 
commonly,  the  pain  is  felt  in  quite  distant,  unrelated  parts.  You  will 
observe  that  these  symptoms  are  not  particularly  definite;  indeed,  it 
is  not  possible  generally  to  distinguish  the  symptoms  of  a  neuralgia 
minor  from  the  early  symptoms  of  tic  douloureux.  We  must,  therefore, 
watch  all  these  cases  anxiously,  with  the  thought  of  a  graver  neuralgia 
in  mind. 

As  for  the  treatment  of  the  milder  forms  of  trifacial  neuralgia,  we 
endeavor  to  remove  the  causative  irritant — in  nose,  ear,  or  mouth, — 
and  we  seek  to  improve  the  patient's  general  condition  by  good  hygiene, 
food,  iron,  quinin,  electricity,  and  an  open-air  life;  and  most  often 
we  succeed.  If  we  fail,  we  may  be  driven  to  a  resection  of  the 
affected  nerve,  after  the  method  of  Thiersch,  which  I  shall  describe 
presently;   or  to  the  injection  of  alcohol  into  the  nerve-tnjnk. 

So  far,  we  have  been  considering  relatively  mild  forms  of  trifacial 
pain.  Let  us  turn  to  that  most  grievous  and  special  form,  tic  doulou- 
reux. 

A  well-established  tic  douloureux  differs  in  many  essentials  from 
the  milder  forms  of  tic.  It  is  not  a  disease  of  young  women,  but  appears 
in  both  sexes,  and  in  middle  life  or  later.  The  victims  frequently  are 
the  subjects  of  marked  arteriosclerosis.  At  first  changes  of  climate, 
weariness,  overwork,  or  any  other  causes  tending  to  depress  the  circula- 
tion may  bring  on  attacks.  The  exact  nature  of  the  process,  however, 
is  unknown  to  us.  As  Cushing  saj's,  "  Let  us  hope  that  some  one  with 
new  histologic  methods  and  possibly  more  extensive  material  may 
solve  this  pathologic  riddle,  for  not  until  the  lesion  is  known  may  we 
expect  to  discover  its  causal  agent."  '  In  other  words,  we  find  no 
constant  histologic  lesion  in  these  cases.  Certain  writers  regard  the 
disease  as  an  ascending  neuritis,  beginning  in  the  peripheral  branches 
of  the  fifth  cranial  nerve.  In  any  case  the  Gasserian  ganglion  eventu- 
ally becomes  involved  in  degenerative  changes,  so  that  only  its  extir- 
^  Harvey  Cushing,  Jour.  Amer.  Med.  Assoc,  April  8,  1905. 


NEURALGIA  699 

pation  or  severance  from  its  central  connections  suffice  to  put  an  end 
to  the  j)iitient's  sufferings. 

Those  sufferings  are  illustrated  by  a  train  of  symptoms  which  are 
characteristic  in  their  agony  when  once  the  disease  is  well  established. 
At  first,  as  I  have  said,  one  scarcely  distinguishes  this  severe  form  of 
tic  from  the  milder  forms.  Usually,  the  second  or  third  divisions  of 
the  nerve  are  attacked  primarily — more  rarely  the  first  division.  The 
pain  begins  in  brief  paroxysms,  darting  along  the  course  of  the  nerve, 
in  the  lips,  the  tongue,  the  nose.  Gradually  attacks  become  more 
frequent  and  more  prolonged,  agonizing  in  character,  so  that  the  sufferer 
groans  or  screams  with  the  intensity  of  his  distress.  The  slightest 
irritant  may  bring  on  the  attack — a  breath  of  air,  a  touch,  an  unexpected 
start.  Natural  sleep  becomes  almost  impossible;  and  the  victims  are 
given  to  the  constant  use  of  opium,  and  may  contemplate  suicide  even. 
Such  symptoms  as  I  have  described  should  serve  to  establish  the  diag- 
nosis. The  examiner  will  find,  in  addition,  that  tender  points  may  be 
determined  at  the  places  where  the  nerves  find  exit  from  their  bony 
canals.  Moreover,  there  are  notable  vascular  changes  and  trophic 
and  secretory  disturbances,  with  flushing  of  the  face,  congestion  of 
the  eyes,  outpouring  of  tears  and  saliva,  running  of  the  nose,  falling  or 
whitening  of  the  hair  or  beard,  and  local  sensations  of  swelling  or  ful- 
ness.    All  these  phenomena  occur  on  one  side  of  the  face  only. 

We  have  been  accustomed  to  state  that  treatment  is  palliative  and 
radical.  As  a  matter  of  fact,  palliative  treatment  is  of  little  service 
and  gives  but  temporary  relief.  Nowadays  one  thinks  of  radical 
treatment  as  consisting  in  some  operation  on  the  Gasserian  ganglion, 
but  that  operation  has  a  decided  mortality  except  in  the  most  ex- 
perienced hands,  and  lesser  operations  often  prove  of  service — operations 
on  the  peripheral  nerves  themselves. 

If  the  disease  be  relatively  recent,  and  if  the  pain  be  assuredly  con- 
fined to  one  branch  only  of  the  nerve,  the  surgeon  may  advantageously 
extirpate  a  large  part  of  that  nerve,  with  the  fairly  assured  hope  that 
the  patient's  pain  will  be  relieved  for  several  months,  if  not  for  years. 
Putnam  and  Waterman  found  the  relief  after  peripheral  operations  to 
last  for  some  ten  months.  This  estimate  is  probably  too  short,  for  the 
statistics  of  these  observers  were  founded  upon  operations  of  the  older 
type — on  simple  resections  of  the  nerves.  We  know  that  these  neuri- 
lemmic  nerves  regenerate  rapidly.  The  resection  of  Thiersch,  there- 
fore, is  recognized  as  the  proper  operation  to-day.  Thiersch's  method 
consists  in  cutting  doTVTi  upon  the  nerve,  seizing  it,  and  twisting  out 
centrally  as  much  of  it  as  possible  from  its  canal.  One,  two,  or  more 
inches  may  be  removed  in  this  way.  The  second  and  third  divisions  are 
best  suited  for  this  form  of  treatment.  Let  me  warn  the  practitioner 
against  assuming  that  the  pain  is  due  to  carious  teeth.  We  see 
patients  who  have  had  all  their  teeth  extracted  from  one  side  of  the  jaw, 
in  the  vain  belief  that  thus  their  pains  might  be  abolished. 

Sundry  injections  into  the  nerve-sheaths  and  into  the  nerves  have 
been  found  beneficial  of  recent  years.     The  favorite  injections  are  osmic 


700 


THE  h?:ai)  and  spine 


acid  and  70  per  cent,  alcohol  (osmic  acid,  1  cc.  of  a  1  per  cent,  solution ; 
alcohol,  1.5  cc),  repeated  injections  may  be  required.  Probably  a 
degeneration  of  the  nerve-trunk  toward  the  ganglion  results.  Un- 
fortunately, this  method  seldom  has  produced  a  pernianont  cure. 

A  more  or  less  persistent  local  anesthesia  results  from  these  peri- 
pheral operations,  but  the  maneuvers  are  practically  safe  always. 

It  seems  scarcely  necessary  to  describe  in  detail  the  method  of 
seeking  and  resecting  these  nerves,  except  the  second  and  third  divi- 
sions. Every  anatomist  knows  how  the  supra-orbital  nerve  emerges 
beneath  the  brow  toward  the  inner  angle  of  the  orbit;  while  the  infra- 


Fig.  443. — Neurectomy,  trifacial.     Second  division — step  1  (adapted  from 

Kocher). 

orbital  nerve  may  be  reached  at  the  infra-orbital  foramen,  one  centi- 
meter below  the  orbital  margin,  at  the  upper  end  of  the  canine  fossa, 
and  vertically  below  the  supra-orbital  notch.  The  second  division 
sometimes  is  sought  at  a  deeper  level  behind  the  antrum,  and  Kocher 's 
operation  is  a  favorite  method  by  which  to  reach  it :  The  incision  below 
the  orbit  is  carried  outward  and  downward  to  the  zygoma.  The 
foramen  and  nerve  are  thus  exposed.  Then,  at  the  outer  end  of  the 
incision,  the  surface  of  the  malar  bone  is  scraped  bare  and  the  bone  is 
divided  with  a  chisel  so  as  to  open  the  sphenomaxillary  fissure  and  to 
remove  the  roof  of  the  infra-orbital  canal.  This  opens  the  antrum. 
The  incision  is  then  retracted  upward  so  as  to  expose  the  frontomalar 


NEURALGIA 


701 


suture,  and  from  here  the  chisel  is  carried  downward,  inward,  and 
backward  toward  the  posterior  part  of  the  sphenomaxiUaiy  fissure, 
through  the  orbital  plate  of  the  sphenoid.  The  zygoma  being  divided, 
tlie  malar  bone  is  dislocated  outward  and  upward,  and  the  contents 
of  the  orbit  are  raised,  when  the  infra-orbital  nerve  may  be  followed 
back  to  the  foramen  rotundum,  where  the  nerve  is  seized  and  pulled 
out. 

The  third  division  of  the  trigeminal  nerve  leaves  the  skull  by  way 
of  the  foramen  ovale,  and  divides  into  anterior  and  posterior  branches. 
The  posterior  branch  is  sensory  and  in  turn  divides  into  the  auriculo- 


Fig.  444. — Neurectomy,  trifacial.     Second  division — step  2  (adapted  from  Kocher). 

temporal,  the  lingual,  and  the  inferior  dental.  The  ling-ual  and  inferior 
dental  are  most  commonly  concerned  in  tic,  and  their  excision  is  part 
of  one  operation  which  Binnie  admirably  describes  somewhat  as  follows : 
Begin  the  incision  at  the  middle  of  the  zygoma  and  carry  the  cut  back- 
ward and  downward  to  a  point  just  below  the  tragus;  then  continue 
along  the  posterior  margin  of  the  jaw  to  its  angle,  and  follow  the  hori- 
zontal ramus  for  about  an  inch.  This  cut  is  a  skin  cut,  and  should  not 
involve  the  facial  nerve,  Steno's  duct,  or  the  parotid  gland.  Now 
make  a  transverse  incision  below  and  parallel  to  Steno's  duct  down 
upon  the  bone,  striking  the  ramus  about  quarter  of  an  inch  below  the 
sigmoid  notch.     Expose  thoroughly  the  bone  and  trephine  it  through 


702 


THE    HEAD    AND    SPINE 


and  through.  Then,  with  rongeur  forceps,  gnaw  away  the  bone  between 
the  trephine  opening  and  the  notch.  Now  retract  foi-ward  the  temporal 
muscle,  remove  obstructing  particles  of  fat,  expose  the  external  ptery- 
goid, and  retract  it  upward,  when  the  lingual  and  inferior  dental  nerves 
will  appear  lying  upon  the  internal  pterygoid  muscle.  Secure  each 
nerve  with  a  suture,  draw  it  down,  trace  the  nerves  up  to  the  fcu-amen 
ovale,  and  divide  them  there.  Then  drag  out  by  torsion  their  peripheral 
portions. 

Such  are  the  best  accepted  methods  of  operating  upon  the  peri- 
pheral parts  of  the  trifacial  nerve.  After  all  is  said,  however,  we  must 
remember  that  these  operations  frequently  do  little  more  than  palliate. 


Fig.  445. — Neurectomy,  trifacial.     Third  divi.'^ion  (adapted  from  Kocher). 

and  that  the  truly  radical  operation  must  be  directed  to  the  (iasserian 
ganglion. 

The  literature  of  Gasserian  ganglion  operations  is  now  enormous, 
and  the  names  of  several  well-known  neurologic  surgeons  are  associ- 
ated with  the  subject.  We  may  not  refer  in  general  terms  even  to  the 
different  methods  advocated  and  the  various  technics  employed.  Suf- 
fice it  to  say  that  surgeons  have  reached  the  ganglion  by  operating  from 
above  and  from  below — by  the  high  temporal,  the  median  direct,  and 
the  low  pterygoid  routes,  and  that  with  these  routes  are  associated  the 
names  of  Rose  and  Andrews,  of  Hartley  and  Krause,  and  of  Cushing.' 
I  am  convinced  that  Harvey  Cushing's  method  is  admirably  satisfac- 
tory, for  it  preserves  the  nerve-supply  to  the  brow,  avoids  the  middle 

^  Binnie  gives  an  admirable  brief  description  of  these  operations  in  the  third 
edition  of  his  Manual  of  Operative  Surgery,  1907. 


NEURALGIA 


703 


meningeal  artoiy,  and  exposes  the  ganglion  by  the  most  direct 
route. 

Cushing's  operation  upon  the  Gasserian  ganglion  is  step  by  step  as 
follows:  the  field  of  operation  about  the  ear  is  shaved,  for  the  purpose 
of  the  surgeon  is  to  seek  the  base  of  the  skull  through  the  temporal 
muscle.  A  slightly  curved  incision  with  convexity  upward  is  made 
almost  entirely  behind  the  hair  margin.  To  quote  Cushing:  "  The  skin- 
flap  is  reflected  downward  and  forward  by  blunt  dissection 

The  temporal  fascia  thus  exposed  is  incised  in  a  line  concentric  with 
the  skin  incision  and  likewise  reflected.  The  zygoma,  which  has  thus 
been  brought  into  view  at  the  lower  angle  of  the  wound,  is  then  shelled 
out  of  its  periosteal  sheath,  not  as  formerl}'  described,  by  making  an 


Fig.  446. — Cushing's  method  of  reaching  the  Gasserian  gangUon  (Cushing). 

incision  along  its  external  surface,  but  by  crowding  foi'W'ard  its  cover- 
ing en  masse.  The  exposed  fibers  of  the  temporal  muscle  may  then  be 
divided  as  usual,  and  the  muscle  scraped  away  with  a  periosteal  elevator 
as  far  dovm  as  the  base  of  the  skull.  In  order  satisfactorilj'  to  expose 
the  skull,  a  little  deeper  retraction  of  the  flap  is  necessary  than  by  the 
older  method.  With  the  soft  parts  and  zygoma  retracted  dowTiward, 
the  surgeon  opens  the  skull  with  chisel  or  gouge  at  the  lowest  possible 
point,  and  enlarges  the  opening  until  it  measures  about  1^  inches.  The 
middle  meningeal  arteiy  lies  on  the  dura  and  runs  obliquely  across  the 
opening  in  the  skull.  Lift  the  dura  with  the  arteiy  from  the  base  of 
the  skull  and  dissect  it  cautiously  away  with  a  blunt  instniment  until 
you  reach  the  foramen  ovale.     Then  retract  cautiously  with  a  pliable 


ro4 


THE   HEAD    AND   SPINE 


spatula  the  cerebral  structures.  The  surgeon  himsel'  should  hold 
the  retractor.  The  inferior  maxillary  nerve  now  serves  as  a  guide 
from  the  foramen  ovale  to  the  ganglion ;  split  the  sheath  of  the  ganglion 
(the  outer  layer  of  the  dura)  and  expose  its  upper  surface.  A^'orking 
still  with  a  blunt  dissector,  isolate  the  ganglion  and  its  sensory  root. 
Then,  with  a  blunt  hook,  pick  up  the  sensory  root,  seize  it  with  a  hemo- 


0»Ji«a.  iy\«ivrS«».^o<«»i«. 


M 


_    r  J  OTCK 


-.._A>-^ 

,/.,. 

f^ 

'Vt»V*\'iAg<o   »w\^<ii.o_. 

,;*• 

•  '^  '  ■) 

t^-^vr^    f"  •    '  ' 

■   if-.^l'^.tir.    .   .' 

/ 

-     /      ;     ' 

N .  ophlhalmicus^'         y        ■     ■      ;      .  Fcram,  n  .sjunnyum 
S .  abiiucens"  I     !      iGancilinn  s,  mdanart 

S.  maxillans    /   A',  mandibtdaris 
Underlying  sheath  oj  dural  envelop 

Fig.  447.- — Sliowins:  relations  of  the  middle  meningeal  artery  to  the  operative  foramen 
before  and  after  elevation  of  the  dura  and  ex{)Osiire  of  the  ganglion  (Cushing). 


Stat,  and  drag  it  out  of  its  deep  attachment  in  the  pons;  thus  you  turn 
the  nerve  out  of  the  opening  which  it  traverses  at  the  attachment  of 
the  tentorium;  and  now  it  lies  loosely  across  the  ganglion."  This 
completes  the  operation  as  Cushing  now  does  it.  The  ganglion,  with 
its  deep  attachments  torn  out,  is  left  lying  in  its  bed,  while  the  three 
divisions  of  the  nerve^the  ophthalmic  and  the  two  maxillary  divisions 


NEUKAL(!IA 


705 


— remain  undisturbed;  for  as  the  author  of  this  operation  states,  "the 
Hberation  of  these  branches  is  the  chief  cause  of  operative  delay  in 
many  cases,  owing  to  the  resultant  bleeding." 

The  wound  is  closed  with  drainage,  the  temporal  muscle  and  fascia 
being  carefully  sutured.  The  drain  may  be  removed  usually  after 
forty-eight  hours. 

in  my  o^^^l  experience  this  operation  has  proved  more  satisfactory 
than  the  operations  of  Hartley,  of  Abbe,  and  the  others,  because  it  is 
more  free  from  hemorrhage  than  are  those  older  and  commonly  accepted 
procedures. 


Operative  foramen 


N.  abducen 


Site  of  operative  _ 
foramen 


A.  meningea,,- 
media 


A.  meningea  media 
Ganglion  semilunare 


Dura  mater  (reflected) 


■Dura  propria  of 
ganglion 


Fig.  448. — Showing  on  the  right,  after  reflection  of  the  dura,  the  ganglion  and 
its  intracranial  branches  liberated  from  their  dural  envelop  and  elevated  by  the 
blunt  dissector  introduced  through  the  operative  foramen;  on  the  left,  the  dura  m 
situ  and  the  relation  of  the  operative  foramen  to  the  ganglion  and  middle  menin- 
geal arteiy  (Gushing). 

All  persons  experienced  in  operating  upon  the  Gasserian  ganghon 
agree  that,  at  the  best,  the  operation  is  a  serious  one,  and  that  it  carries 
with  it  a  definite  mortality,  not  low.  No  man  should  attempt  it  without 
careful  study  and  practice  upon  the  cadaver. 

If  the  patient  recover,  he  is  left  free  from  pain,  though  with  an 
extensive  area  of  anesthesia  involving  half  the  face  and  brow — an 
anesthesia  w^hich  will  be  permanent. 

Sciatica  is  another  serious  affection  which  may  baffle  the  most  care- 
fully considered  treatment,  and  its  causation  is  manifold.  Sometimes 
it  is  benefited  by  surgical  measures. 

We  must  remember  that  the  sciatic  nerve  springs  from  the  sacral 
plexus,  that  the  nerves  which  go  to  make  it  up  are  derived  from  the 
lowest  segment  of  the  spinal  cord;   that  they  are  kno\\-n  as  the  cauda 

45 


706  THE    HEAD    AND    SPINE 

equina  where  they  traverse  the  spinal  canal ;  and  that  after  emerging 
from  the  sacrum,  they  lie  within  the  pelvis  in  near  relation  to  the  pelvic 
viscera  and  the  sacro-iliac  joints.  It  will,  therefore,  be  seen  that  the 
radicles  of  the  sciatic  nerve,  from  their  associations,  are  peculiarly  liable 
to  damage.  Spinal  injuries,  sacro-iliac  disturbances,  pelvic  tumors, 
inflammations,  and  neuritis  all  must  be  considered  when  we  seek  for  the 
cause  of  sciatica;  and  often  the  causative  ailments  may  be  remedied 
b}^  surgical  means. 

The  symptoms  of  sciatica  differ  somewhat  in  different  cases, — the 
disablement  being  sometimes  continuous  and  sometimes  spasmodic, — 
and  again  there  will  be  sharp  paroxysms  of  pain.  It  is  seldom,  however, 
that  the  distress  of  sciatica  is  so  acutel}'  agonizing  as  is  the  distress  of 
trifacial  neuralgia.  Sometimes  pain  extends  along  the  course  of  the 
nerve,  but  more  often  it  centers  in  certain  regions — the  back  of  the 
thigh,  the  sciatic  notch,  the  back  of  the  calf,  and  in  the  popliteal  space. 
Not  infrequently,  especially  when  sacro-iliac  disease  causes  sympto- 
matic sciatica,  the  leg  pain  is  associated  with  lumbar  pain  and  the 
ailment  is  confounded  with  so-called  lumbago. 

Should  neuritis  cause  the  sciatica,  there  may  be  present  muscular 
weakness  and  atrophy,  numbness,  tingling,  a  feeling  of  coldness,  trophic 
disturbances,  and  herpes.^  The  patient  often  attempts  to  relieve  this 
distress  by  relaxing  the  normal  tension  on  the  nerve — relaxing  it  by 
tilting  his  pelvis  and  bending  his  trunk  toward  the  affected  side.  This 
almost  involuntary  maneuver  may  lead  to  the  characteristic  sciatic 
scoliosis. 

The  treatment  of  sciatica  in  any  given  case  must  depend  alwa3's 
on  the  cause.  A  central  lesion  (tumor  of  the  cord)  must  be  removed; 
pelvic  tumors  must  receive  surgical  consideration;  and  sacro-iliac 
disease  must  be  attacked  by  rest  and  apparatus.  The  neuritis  is  best 
treated  by  absolute  rest,  by  splinting,  and  immobilization,  while  local 
applications,  the  actual  cautery,  blisters,  and  sometimes  massage, 
often  are  effective.  Above  all  things,  withhold  morphin.  Neurectasis 
has  been  beneficial  sometimes,  and  the  nerve-stretching  may  be  done 
with  considerable  vigor,  many  pounds  of  tension  being  put  upon  the 
affected  nerve.  The  common  site  for  stretching  of  the  sciatic  nerve  is 
just  below  the  gluteus  maximus  muscle,  where  the  nerve  lies  beneath 
the  skin  and  the  deep  fascia,  in  a  line  from  the  middle  of  the  popliteal 
space  to  the  junction  of  the  middle  and  inner  third  of  that  line  which 
connects  the  ischial  tuberosity  with  the  outer  border  of  the  great  tro- 
chanter. At  the  best,  all  these  operative  methods  are  as  yet  sub  judiee. 
Our  reliance  must  be  upon  rest  and  massage  and  removal  of  the  offending 
cause  whenever  it  may  be  found. 

There  are  numerous  other  peripheral  nerve  ailments  which  are 
coming  more  and  more  within  the  surgeon's  province.  Let  us  consider 
briefly  and  in  a  few  paragraphs  the  technic  of  operations  upon  the 
nerves,  for  neuromata,  wounds  of  the  nerves,  and  sundry  foi'ms  of  tic. 

1  For  an  admirable  account  of  peripheral  nerv-e  surgery  see  the  chapter  on  The 
Surgerj'  of  the  Nerves,  by  George  Woolsey,  in  Keen's  Surgery',  vol.  ii,  p.  C86. 


OPERATIONS    UPON  THE    NERVES  /U/ 

OPERATIONS  UPON   THE  NERVES 

Whatever  theory  we  may  choose  to  adopt  regarding  the  regenera- 
tion of  severed  nerves,  or  nerves  damaged  b}'  disease,  certain  it  is 
that  regeneration  can  be  accomphshed  only  through  a  complete  ana- 
tomic reunion  of  the  distal  portion  with  the  sound  central  portion  of 
the  affected  nerve.  Even  though  we  admit  that  the  peripheral  portion  of 
a  nerve  may  regenerate  without  a  central  union,  that  regenerated  portion 
must  remain  functionless  until  the  union  be  reestablished.  Within 
recent  years  only  have  surgeons  met  with  SLny  degree  of  success  in 
reestablishing  sound  anatomic  nerve-paths  in  damaged  nerves.  For 
the  satisfactory  repair  of  nerves  certain  factors  are  essential,  while  the 
mechanics  of  the  operation  are  difficult  and  delicate.  We  must  expose 
carefully  and  thoroughly  the  nerve  upon  which  we  are  to  work.  We 
must  avoid  damage  to  its  sti-ucture  while  we  free  it  from  surrounding 


m 


\ 


Fig.  449. — Methods  of  ner\'e  suturing:  A,  B,  C,  Sutures  passing  through  entire 
thickness  of  ner\'e  and  sheath;  D,  E,  sutures  passing  through  nerve-sheath  only 
(Bickham). 

scar  tissue.  After  freeing  it,  w^e  must  stretch  it  carefully  in  order  to 
render  easy  the  desired  approximation.  In  stretching  the  nerve  we 
must  not  handle  it  roughly  with  forceps,  but  must  seize  its  end  in 
fingers  guarded  by  gauze;  and,  finally,  after  we  have  made  our  new 
sutured  union,  we  must  provide  against  subsequent  encroachment 
by  scar-tissue  about  the  hne  of  suture.  For  this  purpose  I  have 
found  Cargile  membrane  wrapped  about  the  nerve  to  be  efficient. 
Some  writers,  J.  B.  Murphy  especially,  advocate  the  use  of  liv- 
ing fascia  rather  than  Cargile  membrane,  but  both  substances  are 
effective.  We  must  employ  careful  after-treatment — immobilizing 
the  affected  parts  until  sound  wound-healing  has  taken  place;  and 
then  by  employing  massage,  active  and  passive  movements,  and  elec- 
tricity for  many  months.  These  measures  of  treatment  have  no  effect 
in  stimulating  nerve  regeneration,  but  we  employ  them  to  prevent 


708 


THE    HEAD    AND    SPINE 


muscle  apathy,  and  those  trophic  changes  which  are  Hable  to  occur 
iii  the  body  structures  long  cut  off  from  nervous  .stimuli. 

Many  .surgeons  in  the  past  have  neglected  the  methods  of  after-treat- 
ment which  I  have  described — have  centered  their  efforts  upon  the 
mechanical  repair  of  the  damaged  nerve,  and  when  functional  failure 
has  resulted,  have  been  led  to  feel  that  nerve  surgery  is  of  little  or  no 
value.  On  the  contrary,  we  know  from  abundant  experience  that 
damaged  nerves,  when  properly  handled,  regenerate  eagerly,  with  a  final 
though  delayed  restoration  of  function. 

The  suture  of  nerves,  however,  is  a  mechanical  act  demanding 
our  most  careful  effort.  Divided  nerves  often  can  be  stretched  into 
approximation,  and  when  approximated,  must  be  made  to  lie  in  easy 


Fig.  450. — Methods  of  nerve  suturing: 
A,  B,  Sutures  passing  through  sheatli  and 
part  of  nerve;  C,  sutures  through  sheath, 
reinforced  by  relaxation  suture  through 
entire  nerve  (Bickham). 


Fig.  451. — Neuroplasty — imion 
by  sphtting  both  ends  of  nerve  and 
uniting  split  ends  end  to  end  (Bick- 
ham). 


apposition,  that  there  be  no  strain  upon  the  retaining  sutures.  We 
must  endeavor  to  avoid  damage  to  nerve-fibers  when  passing  our 
sutures.  Frequently  several  strands  of  the  finest  .silk  passed  through 
the  nerve-sheath  will  answer  our  purpose,  or  it  may  be  necessary  to  pass 
deeply  through  the  nerve  itself  one  or  two  sutures  of  chromicized 
catgut. 

It  often  appears,  however,  especially  in  the  case  of  nerves  nipped 
in  bone  fractures,  that  a  ready  approximation  of  the  divided  ends  is 
impossible.  We  must  then  endeavor  in  some  fashion  to  bridge  the  gap. 
Neuroplasty  has  been  for  many  years  a  favorite  method  of  joining 
the  remote  nerve-ends.  This  method  has  not  infrequently  failed,  per- 
haps because  the  time  elapsed  since  the  injury  was  too  long  to  permit, 


OPERATIONS   UPON  THE    NERVES 


709 


"WVMMJJJJM'JyMW^V^^J)JJ/^WJ/J>JJ//M/^JJJ/J//j/i 


of  a  peripheral  end  regeneration.  Other  methods  have  been  attempted, 
but  with  limited  success.  Nerve  transplantation— the  insertion  of  a 
bit  of  foreign  nerve  into  the  gap— has  been  advocated.  Ballance  and 
Stewart  point  out  that  the  inserted  nerve  does  not  itself  regenerate, 
but  serves  as  a  trellis  for  the  training  of  the  new  down-shooting  fibers. 
This  operation  has  proved  of  small  value.  In  the  same  way  a  trellis 
of  catgut  between  the  nerve- 
ends    has    been    tried    with 

small  effect,  and  a  tubular 
trellis  (hollow  bone  tube)  has 
served  no  purpose.  In  certain 
desperate  cases  some  surgeons 
have  resected  the  long  bones 
themselves  in  order  to  allow  of 
proper  nerve  approximation. 
Nerve  anastomosis,  how- 
ever, gives  the  greatest 
promise  for  the  regeneration 
of  damaged  nerves,  and  the 
brilliant  work  of  Gushing, 
Frazier,  Spiller,  and  van 
Kaathoven  in  these  Hnes 
seems  full  of  promise.  The 
mechanical  principle  of  the 
operation  is  easy.  A  por- 
tion of  a  sound  nerve,  lying 
in  the  neighborhood  of  its 
damaged  fellow,  is  trans- 
planted into  the  peripheral 
damaged  end.  The  accom- 
panying figures,  taken  from 
Woolsey's  article,  illustrate 
admirably  the  purpose  and 
technic  of  this  operation. 
We  shall  have  occasion  in 
subsequent  paragraphs  to 
study  briefly  some  of  the 
more  important  nerve  anas- 
tomoses. 

Neuromata,   especially 
painful  nerve  tumors. 


B  -  ,^.,^,u^^m^!!A^.MWm't() 


Fig.  452. — Various  modes  of  anastomosis:  A, 
Represents  the  imaffected  nerve,  B,  the  affected 
nerve  (Spiller,  Frazier,  and  van  Kaathoven). 


'amputation  neuromata,"  are  extremely 
True  neuromata  are  rare  and  small.  Neuro- 
fihromata  are  common  enough  and  reach  a  considerable  size— as  large, 
perhaps,  as  a  small  peanut.  The  amputation  neuroma  is  properly  a 
neurofibroma.  When  the  nerve  is  severed  in  the  amputation,  its 
inherent  force  of  regeneration  stimulates  often  a  rapid  development  of 
this  small  tumor,  at  the  nerve's  cut  end  especially,  when  the  nerve-end 
lies  in  an  irritative  cicatrix.  The  common  maneuver  of  pulling  the  nerve 
well  do^Ti  so  as  to  cut  it  high  by  no  means  does  away  with  the  possibil- 


710 


THE   HEAD    AND   SPINE 


ity  of  the  neuroma's  occurrence.  These  neuromata  cause  a  constant, 
nagging,  burning  pain.  Tliey  prevent  the  weaiing  of  an  artificial  Hmb, 
and  make  the  cripple  wretched.  Kecently  we  have  been  able  to  do 
away  with  these  amputation  neuromata  through  an  opei-ation  which 
leaves  no  nerve-ends.  We  take  the  nerve-ends  in  the  amputation 
stump  and  suture  them  to  each  other.  This  is  a  primary  suture  and 
is  followed  by  a  prompt  union  with  each  other  of  the  central  nerve- 
stumps. 

The  treatment  of  the  neuromata  themselves  is  simple  enough,  though 
the  results  are  not  always  entirely  satisfactory.  Nerve-end  neuromata 
should  be  excised,  and  the  nerve-stumps  should  be  so  placed  as  to  be 
free  from  irritation  by  the  cicatrizing  of  the  wound.  This  may  be 
accomplished  by  laying  the  nerve  smoothly  in  fascial  jjlanes,  or  by 
wrapping  it  in  Cargile  membrane.     Best  of  all  is  the  practice  of  drawing 

out  the  refreshed  nerve-ends  and 
stitching  them  to  each  other  in  the 
fashion  of  an  end-to-end  anasto- 
mosis, as  described  in  the  last  para- 
graph. By  this  maneuver  all  nerve- 
ends  are  eliminated  so  that  the 
ordinary  amputation  neuroma  finds 
no  lodgment.  When  the  neuroma 
lies  upon  the  nerve-sheath  in  the 
course  of  the  nerve,  and  not  at  its 
end,  the  little  tumor  may  readily  be 
shelled  out.  In  all  these  operations 
on  nerves  the  surgeon  must  observe 
careful  hemostasis,  and  must  enjoin 
absolute  rest  of  the  part  for  at  least 
two  weeks.  The  results  of  these 
operations  are  good,  as  a  rule. 
Wounds  and  injuries  of  nerves  occur  frequently  and  are  of  im- 
portance only  as  they  concern  the  subsequent  function  of  the  parts 
supplied  by  the  nerve.  When  the  nerve  is  but  partially  severed, 
reunion  may  take  place  without  special  treatment,  provided  the  wound 
be  kept  free  from  infection.  Lacerations  of  nerves  are  of  manifold 
character  and  significance,  and  subsequent  degenerations  of  the  peri- 
pheral ends  of  the  nerve  may  occasion  a  great  variety  of  symptoms. 
No  man  may  say  at  once  from  the  symptoms  observed  how  extensively 
a  nerve  is  injured.  It  is  well,  therefore,  always  to  expose  the  suspected 
nerve  and  to  examine  its  condition.  A  laceration,  a  parently  trifling, 
may  lead  to  extensive  changes  within  the  nerve  substance  and  in 
the  sheath  of  Schwann,  with  a  resulting  soar  formation  completely 
blocking  the  nerve.  Or  a  nerve  apparently  little  damaged,  but  lying 
in  a  field  of  lacerated  tissue,  ma}-  become  nipped  and  thrown  out  of 
action  by  a  resulting  extensive  cicatrix.  For  all  such  reasons,  suspicion 
of  nerve  damage  imposes  upon  us  careful  exploration  and  investigation. 
We  must  clear  away  the  blood-clot ;  must  place  the  nerve  as  far  as  pos- 


Fig.  45.3. — Nerve  anastomosis  in 
stump.  A  diagram  showing  cross-sec- 
tion through  lower  third  of  the  right 
leg,  the  nerves  Ijeing  enlarged  to  show 
sutures. 


OPERATIONS    UPON   THE    NERVES 


711 


sible  from  damaged  bone;  must  repair  obvious  gross  lesions  in  the 
ner\'e ;  must  strip  off  carefully  extraneous  tissue,  and  replace  the  nerve, 
preferabh'  wrapped  in  Cargile  membrane,  in  a  bed  which  shall  admit 
of  ready  healing  without  undue  external  pressure.  Be  it  remembered 
always  that  severed  nerves,  under  favorable  conditions,  unite  promptly, 
though  a  restoration  of  function  will  be  many  weeks  delayed.     Primary 


Fig.  454. — Illustrating  method  of  spinofacial  anastomosis  (Harvey  Gushing). 

suture  of  damaged  nerves  gives  a  far  better  prognosis  for  anatomic  and 
functional  restoration  than  does  late  suture,  though  recent  experience 
teaches  that  late  suture,  even  after  the  lapse  of  two  or  more  years, 
sometimes  ma}'  be  followed  b}'  excellent  anatomic  repair  and  functional 
improvement  in  the  parts  supplied  by  it. 

Nerve  anastomosis  and  nerve-grafting  are  coming  to  occupy  an 
important  place  in  nerve  surgery — for  paralyses  and  to  relieve  spasm. 


712 


THE   HEAD    AND   SPINE 


Paralysis  of  the  facial  nerve  is  a  not  uncommon  condition  and  may- 
be the  result  of  various  operations  and  injuries.  It  may  follow  disease 
of  the  petrous  bone  and  of  the  middle  ear.  It  may  result  from  operations 
upon  the  parotid  gland  and  from  operations  on  the  neck  just  below 
the  ear,  as  well  as  from  fractures  at  the  base  of  the  skull.  Rarely  it 
may  be  possible  to  secure  the  divided  ends  of  the  facial  nerve,  and  to 
unite  them  by  direct  suture,  but  more  conmionly  the  surgeon  is  unable 
to  find  the  proximal  portion  of  the  nerve,  so  that  a  restoration  of  facial 
function  seems  impossible.  In  such  a  case,  as  numerous  investigators 
have  demonstrated,  one  may  graft  into  the  distal  portion  of  the  facial 
nerve  an  active  and  functionating  nerve  in  its  neighborhood.  The 
spinal  accessor}^  and  the  hypoglossal  nerves  have  been  used  for  this 
anastomosis.     While  some  operators  claim  special  advantages  for  the 

use  of  the  one  nerve  or  the  other, 
it  has  seemed  to  me  that  the  spinal 
accessory  nerve  is  subject  to  fewer 
disadvantages  than  is  the  hypo- 
glossal nerve,  w'hen  so  treated.  The 
spinal  accessory  nerve  normally 
supplies  structures  whose  loss  of 
function  is  of  no  particular  imi^or- 
tance,  and  every  surgeon  knows  from 
his  experience  in  operating  for  spas- 
modic torticollis  that  section  of  the 
spinal  accessor}'  nerve  rarely  results 
in  a  permanent  paralysis  of  the  mus- 
cles supplied  by  that  nerve.  Gush- 
ing especially  advocates  the  spino- 
facial  anastomosis,  and  I  have  repro- 
duced here  his  own  interesting 
sketch  which  illustrates  the  proce- 
dure (Fig.  454).  The  operation  is 
not  easy.  The  nerves  involved  are 
small,  and  their  suturing  demands 
painstaking  care.  If  the  operation  is  properly  done,  however,  a  grad- 
ual return  of  facial  function  is  seen,  so  that  in  the  course  of  months  little 
deformity  remains. 

Facial  spasm  or  convulsive  tic  is  another  condition  which  may 
be  cured  by  the  spinofacial  anastomosis.  In  these  cases,  however, 
the  operation  must  be  regarded  as  a  last  resort.  Few  patients  are 
willing  to  submit  to  the  possibly  complete  facial  paralysis  which  results 
if  the  anastomosis  fails;  while  convulsive  tic  may  often  be  relieved 
by  some  operation  for  disease  of  the  teeth,  eyes,  nose,  stomach,  uterus, 
etc.,  inasmuch  as  the  tic  not  infrequently  is  of  a  reflex  character. 

To  find  the  spinal  accessory:  Make  an  incision  3  inches  long  from 
the  mastoid  process  downward  along  the  anterior  border  of  the  stemo- 
mastoid  muscle.  Draw  the  muscle  backward.  Plunge  the  finger  into 
the  wound  and  feel  the  transverse  process  of  the  atlas,  which  is  covered 


Fig.  455. — Facial  paralysis — .six 
weeks  after  injurj'.  Effort  to  close  eye 
(Harvey  Cushing). 


OPERATIONS  UPON  THE  NERVES  713 

by  the  digastric  muscle.  The  digastric  is  the  guide  to  the  nerve, 
which  passes  between  the  bony  process  and  the  muscle,  emerging  at 
the  lower  edge  of  the  digastric  and  passing  to  the  sternomastoid.  The 
inexperienced  operator  will  always  be  surprised  to  find  that  the  nerve 
lies  much  higher  than  he  had  expected. 

Spasmodic  torticollis,  or  wry-neck,  frequently  is  due  to  an  irrita- 
tion of  the  accessory  nerve — an  irritation  usually  of  central  origin. 
Division  of  the  spinal  accessory  nerve  may  benefit  the  ailment,  but 
must  always  be  regarded  as  an  experimental  operation.  Often  the 
muscular  branches  of  the  cervical  nerves  must  be  divided  also.  Keen's 
well-known  operation  involves  paralyzing  the  large  posterior  root  of 
the  neck  muscles  through  the  section  of  the  first,  second,  and  third 
cervical  nerves.  The  largest  of  these  nerves  is  the  occipitalis  major, 
which  first  should  be  found  and  resected.  It  is  a  landmark  which 
serves  to  identify  the  others.  The  steps  of  the  operation  are  these : 
Make  a  four-inch  incision  transversely  across  the  neck,  starting  three- 
fourths  of  an  inch  below  the  lobule  of  the  ear.  Sever  the  trapezius 
muscle.  Raise  the  trapezius  and  isolate  the  occipitalis  major,  whose 
level  is  about  half  an  inch  below  the  level  of  the  skin  incision.  Care- 
fully cut  through  the  complexus,  following  the  nerve  in  its  course 
through  that  muscle.  By  this  dissection  one  finds  the  nerve's  bifurca- 
tion from  the  second  cervical,  and  should  excise  a  long  piece  from 
both  nerves.  Then  search  for  and  resect  the  first  cervical,  which  lies 
deep  in  the  wound  above  the  second.  One  finds  it  by  outlining  the 
suboccipital  triangle,  bounded  by  the  two  oblique  muscles  and  the 
rectus  capitis  posticus  major.  Search  for  and  resect  the  external 
branch  of  the  posterior  division  of  the  third  cervical,  which  lies  about 
one  inch  below  the  second,  already  cut.  The  surgeon  may  then  reunite 
the  muscles  in  order  to  obviate  a  needless  deformity.  After  any  opera- 
tion upon  the  nerves  of  the  neck  involved  in  spasmodic  torticollis 
accurate  wound  healing  must  be  sought  through  perfect  hemostasis, 
approximation  of  the  cut  surfaces,  and  many  weeks  of  immobilization 
and  support  by  a  Thomas  collar  or  some  similar  apparatus. 

Incidentally,  one  observes,  as  a  matter  of  no  slight  importance,  that 
the  relief  or  cure  of  spasmodic  torticollis  sometimes  is  secured  by  other 
than  operative  measures — by  long-continued  immobilization  with  ap- 
propriate apparatus. 

The  phrenic  and  pneumogastric  nerves  sometimes  may  be  subject 
to  surgical  operations — operations  following  nerve  injuries  from  wounds 
of  violence  or  from  operations.  Injury  of  one  phrenic  nerve  paralyzes 
half  the  diaphragm,  so  that  the  repair  of  the  injured  nerve  should  be 
sought,  though  its  reunion  is  not  absolutely  essential  to  life.  This 
nerve  is  the  most  important  branch  of  the  cervical  plexus,  and  lies  upon 
the  scalenus  anticus  muscle,  where  it  may  easily  be  found. 

Division  of  the  pneumogastric  (vagus)  nerve  on  one  side  only  causes 
no  marked  change  in  the  pulse-rate,  the  respiration,  or  the  digestive 
organs,  but  it  does  result  in  a  paralysis  of  the  vocal  cord  on  that  side. 
It  may  be  possible  successfully  to  suture  the  vagus. 


714 


THE    HEAD    AND    SPIXE 


The  brachial  plexus  frcfiuently  is  the  site  of  serious  damage, 
either  from  traumatism  at  birth  or,  more  commonly  in  men,  from 
heavy  crushing  injuries.  The  resulting  paralyses  must  be  studied 
carefully  by  a  neurologic  expert,  for  it  is  extremely  difficult  to  determine 
readily  the  site  of  the  laceration  hi  the  complex  anastomotic  mechanism. 
The  accompanying  figures,  taken  from  Woolsey's  article,  illustrate  this 
anastomosis.  Operators  have  attempted  to  repair  these  damaged 
nerves,  but  with  varying  and  uncertain  results.  The  obvious  indication 
is  to  cut  down  upon  the  plexus  through  a  long  incision  in  the  neck,  and 
thoroughly  and  carefully  to  expose  the  injured  structures.     Rarely  is 


Fig.  l."»(i.— Dissection  of  the  operative  field  in  brachial  birth  palsy  (Clark, 
Taylor,  and  Prout):  A,  Scalenus  anticus  muscle;  B,  phrenic  nerve;  C,  internal 
jugular  vein;  D,  transversalis  colli  artery,  divided;  E,  seventh  cervical  root;  F,  omo- 
hyoid muscle;  G,  fifth  cervical  root;  H,  scalenus  medius  muscle;  I,  sixth  cervical 
root;  J,  transversalis  colli  artery;  K,  suprascapular  nerve;  L,  nerve  to  subclavian 
muscle;  M,  clavicle;  N,  nerve  to  scalenus  anticus  muscle  (Woolsey  in  Keen's 
Surgery). 


it  possible  directly  to  unite  in  their  proper  relations  the  severed  nerves. 
The  construction  of  new  and  complicated  anastomoses  may  be  impera- 
tive. The  functional  results  depend  upon  two  factors:  the  accuracy 
of  the  wound  healing  and  the  ability  of  the  patient  to  coordinate  in  the 
presence  of  the  strange  new  nerve-relationships  established.  This  last 
difficulty,  however,  is  not  peculiar  to  nerve  anastomoses  in  this  region, 
but  is  true  of  all  nerve  anastomoses. 

The  various  terminal  nerves  of  the  brachial  plexus  are  subject  to 
their  own  injuries  likewise,  and  as  they  control  the  complex  movements 
of  the  arm  and  hand,  their  damage  is  of  vital  importance  to  all  men.  It 
is  needless  here  to  take  up  in  detail  these  subjects  further  than  to  remind 


OPERATIONS   UPOX   THE    NERVES 


715 


the  reader  of  two  or  three  of  the  more  important  injuries  to  the  nerves 
of  the  arm. 

Fracture  of  the  humerus  or  an  extensive  wound  of  the  upper  arm 
may  destroy  the  vmsculospiral  nerve,  when  the  characteristic  wrist- 
drop ensues. 

The  uhiar  nerve  may  be  damaged  or  destroyed  through  a  fracture 
about  the  elbow-joint.     There  results  the  so-called  "  claw-hand,"  due 


p 

J 

/    ■ 

K 

//                      .                               L 

M 

p.  :' 

N 

£       V.   i.  y^^^^^i^)         _ 

0 

''"•: 

...Q 

^ — 

^%<*S:^ 

R 

Uc         *-      \ 

Kr 

■^^^  S    1 

^^^ 

^^^iJL 

■*  '*4 

fe^-^^' 

X 

u 

Fig  457  —Dissection  of  the  operative  field  in  brachial  birth  palsy  (Clark,  Taylor, 
and  Prout)-  A,  Phrenic  nerve;  B,  scalenus  anticus  muscle;  C,  internal  jugular  vem; 
D  transversaHs  coUi  artery;  E,  omohyoid  muscle  divided;  F,  suprascapular  artery 
divided-  G,  eighth  cervical  and  first  dorsal  roots;  H,  external  anterior  thoracic  nen^e; 
I  subclavian  artery;  J,  fifth  cervical  root;  K,  sixth  cervical  root;  L,  scalenus  medius 
muscle-  M  nerve  to  scalenus  anticus  muscle;  N,  suprascapular  ner^^e ;  0,transver- 
salis  co'm  artery;  P,  seventh  cervical  root;  Q,  omohyoid  muscle,  divided;  E,  supra- 
scapular artery;  S,  clavicle  and  subclavius  muscle,  divided  and  retracted;  T  deltoid, 
pectorahs  minor,  pectorafis  major  (muscles);  U,  nerve  to  subclavius  muscle  (Woolsey 
in  Keen's  Surgery) . 

to  paralysis  of  the  flexors  in  the  proximal  phalanges,  except  of  the 
thumb.  There  is  an  associated  cutaneous  anesthesia  which  varies  on 
account  of  the  uncertain  nerve  anastomoses  which  may  exist. 

The  median  nerve  supplies  those  flexor  muscles  of  the  forearm  and 
hand  not  supplied  by  the  ulnar.  Damage  to  the  median  nerve  causes 
loss  of  flexion  of  the  second  phalanges  of  all  the  fingers,  and  of  the 
third  phalanges  of  the  forefinger  and  middle  finger,  with  loss  of  flexion, 


716  THE    HEAD    AND    SPINE 

abduction  and  opposition  of  the  thumb,  so  that  the  thumb  lies  in  exten- 
sion, adducted  against  the  forefinger — the  so-called  "  ape-hand."  Pro- 
nation of  the  forearm  is  lost  and  the  flexion  of  the  wrist  is  weak. 

Injuries  to  these  nerves  result,  however,  in  curiously  uncertain 
phenomena.  I  have  here  described  the  characteristic  phenomena,  but 
immediate  suture  after  damage  may  in  certain  cases  cause  a  variation 
in  the  nature  of  these  paralyses,  greatly  to  the  confusion  of  the  examiner. 
In  case  continued  doubt  of  the  nature  of  the  injury  exists,  the  surgeon 
may  justifiably  cut  down  upon  the  nerve  and  ascertain  its  exact  condi- 
tion. 

There  are  sundry  other  peripheral  nerves  which  the  surgeon  may 
have  occasionally  to  search  out  and  operate  upon  in  various  ways. 


The  intercostal  nerves  may  be  the 
subject  of  a  neuralgia  so  extreme— from 
traumatism  or  in  the  course  of  a  zoster 
— that  their  stretching  or  resection  seems 
wise.  In  order  to  expose  these  nerves 
make  an  incision  parallel  with  the  spin- 
ous processes  and  two  inches  from  them. 
Expose  the  intercostal  muscles  and  divide 

them  near  the  lower  border  of  the   ribs.    '  ,58._wrist-drop  from 

Thus  you  will  brmg  mto  view  the  nerve     musculospiral  paralysis  (Massa- 
lying  below  the  vessels.     The  operation  is     chusetts  General  Hospital), 
an  easy  one. 

I  have  already  spoken  of  stretching  the  sciatic  nerve  which  lies 
behind  the  head  of  the  femur  at  the  point  of  election  for  stretching. 
The  sciatic  nerve  rarely  suffers  traumatism  from  any  cause,  but  may 
be  involved  in  a  tumor,  and  may  be  resected  and  sutured  with  expecta- 
tion of  its  restoration.  In  all  cases  of  sciatica  the  surgeon  should  bear 
in  mind  the  possibility  of  sacro-iliac  disease  or  injury. 

The  external  popliteal  or  peroneal  nerve,  which  winds  around 
the  fibula  just  below  its  head,  is  sometimes  injured.  This  nerve  sup- 
plies the  anterior  tibial  group  of  muscles,  which  are  frequently  affected 
in  anterior  poliomyelitis.  In  such  cases  the  surgeon  will  have  an  op- 
portunity to  reinnervate  the  paralyzed  muscles  through  anastomosis 
of  the  intact  internal  popliteal  nerve  with  the  distal  portion  of  the 
peroneal. 


OPERATIONS   UPON   THE   NERVES 


717 


The  cervical  sympathetic  nerves  occasionally  are  attacked  by  the 
surgeon  for  such  conditions  as  glaucoma,  exophthalmic  goiter,  epilepsy, 
and  trifacial  neuralgia.  I  see  no  reason  to  believe  that  this  mode  of 
treatment  will  remain  in  vogue  for  these  diseases,  but  one  should 
not  overlook  the  technic  of  the  operation.  The  maneuver  is  called 
by  the  extraordinary  term  "  sympathectomy,"  and  j-ou  should  perform 
it  as  follows:  Make  an  incision  from  the  mastoid  process  downward 
along  the  posterior  border  of  the  sternomastoid  muscle  to  an  inch  below 
the  clavicle,  avoiding  the  spino-accessory  nerve.  Free  the  muscle,  and 
draw  it  toward  the  median  line,  together  with  the  vessels  and  nerves 
of  the  neck.  Look  for  the  sympathetic  nerve  in  the  middle  of  the 
wound,  either  on  the  posterior  sheath  of  the  vessels  or  on  the  vertebral 
column,  where  it  lies  in  a  special  sheath.  The  books  say  you  shall  find 
it  easily,  but  this  depends  upon  your  skill  as  an  anatomist.  In  order 
to  make  sure  of  its  identity,  trace  the  nerve  upward  to  its  superior 
ganglion— then  divide  the  ganglion  fibers  and  tear  away  the  nerve- 


Fig.  459. — Claw-hand.     Griffin  clutch  of  Duchenne  (Fowler). 

tnmk  which  leads  upward  toward  the  skull.  Next  seek  out  the  inferior 
thyroid  artery  through  pulling  it  up  from  its  bed  by  tension  on  the 
already  freed  sympathetic  nerve  w^hich  surrounds  it.  Elevate  the  nerve 
and  the  artery  together  and  separate  them  carefulh'.  The  next  step 
is  to  remove  the  inferior  ganglion — a  difficult  undertaking,  since  the 
ganglion  lies  deeply  embedded  at  the  base  of  the  neck  behind  the  clavicle, 
against  the  head  and  neck  of  the  first  rib,  between  the  scalenus  anticus 
and  longus  colli  muscles,  and  just  above  the  pleura.  We  use  the  already 
liberated  tnmk  of  the  nerve  as  a  guide,  and  penetrate  to  the  ganglion 
which  is  adherent  to  the  vertebral  artery,  embracing  it  in  a  fine  mesh- 
work.  Then  remove  the  ganglion.  The  reader  will  see  that  this  is  an 
operation  not  lightly  to  be  undertaken,  even  by  the  skilled  anatomist. 
The  operation  is  tedious,  somewhat  bloody,  not  without  danger,  and 
most  uncertain  in  its  effects  upon  the  offending  organ.  After  the 
operation  is  over  one  must  attend  carefully  to  the  dressings  and  the 
wound  healing,  for  a  septic  infection  deep  in  the  neck  is  a  serious  matter. 


718  THE   HEAD   AND   Sl'INE 

The  surgeon  should  repair  the  damaged  structures  carefully  layer  by 
htyer;  he  should  employ  deep  drainage  if  there  is  persistent  oozing; 
and  finally  he  should  support  the  neck  carefully  and  immovably  in  a 
heavy  dressing  until  all  thinger  of  sepsis  and  hemorrhage  be  past. 

The  reader  will  see,  from  his  perusal  of  this  chapter,  that  the  sur- 
gery of  the  spine  and  peripheral  nerves  is  reaching  out  in  many 
new  and  unwonted  directions.  This  is  a  field  little  cultivated  as  yet, 
of  strange  and  unexpected  possibilities,  vigorously  tilled  of  late  by  an 
increasing  number  of  investigators.  Even  as  one  writes  he  feels  that 
much  which  is  hero  said  shortly  must  be  revised.  Like  all  new  surgical 
fields,  this  is  one  of  growing  interest  and  of  surpassing  possibilities. 


PART  VII 

MINOR   SURGERY 
DISEASES   OF  STRUCTURE 


CHAPTER  XXVI 
MINOR  SURGERY^ 


The   Examination  and   Study  of   Cases?   Wounds ;   Frac- 
tures; Local  Infections?  Massage 

About  twenty  years  ago  some  one  coined  the  phrase  ''  antiseptic 
conscience."  I  think  it  was  Howard  A.  Kelly,  of  Baltimore.  That 
phrase  and  the  thought  it  contains  were  once  essential,  because  twenty 
years  ago  most  of  the  men  who  were  doing  the  surgery  of  the  world 
belonged  to  the  generation  which  in  its  youth  knew  the  old  sepsis. 
To  them  the  principles  and  practice  of  antiseptic  surgery  came  haltingly 
and  often  imperfectly.  They  had,  indeed,  need  to  cultivate  the  anti- 
septic conscience;  but  they  had  conscience  for  many  other  things- 
great  principles  underlying  good  surgery,  principles  as  important  to- 
day as  ever  they  were.  One  is  impressed  at  times  with  the  conviction 
that  many  of  those  sound,  ancient  principles  latterly  are  being  pushed 
back  into  a  subordinate  position. 

To-day  a  majority  of  the  surgeons  in  active  practice  have  grown 
up  with  the  antiseptic  idea.  In  the  course  of  their  development  the 
antiseptic  conscience  has  become  part  of  their  being.  That  intangible 
thing  which  we  call  surgical  instinct  includes  and  partakes  of  this 
same  conscience.  There  is  no  danger  of  any  man  who  has  received 
his  training  in  the  past  twenty  years  going  far  astray  with  that  con- 
science to  prompt  him.  Every  source  of  surgical  infection  has  been  so 
thoroughly  and  universally  studied  that,  with  one  or  two  exceptions, 
our  aseptic  technic  is  now  perfect,  or  as  near  perfection  as  it  is  hkely 
soon  to  become. 

But  there  are  those  other  general  principles  which  were  so  miportant 
to  the  former  generations. 

1  This  chapter  is  a  reproduction,  in  large  part,  of  a  little  book  I  published  in 
1903  Clinical  Talks  on  Minor  Surgery.  That  book  was  cast  in  the  direct,  personal 
lecture-room  form— a  form  which  may  not  be  thought  appropriate  for  a  more  tormai 
treatise  on  general  surgery,  but  the  " Chnical  Talks"  has  been  so  kindly  received 
that  I  am  persuaded  to  embody  it,  with  little  change,  m  this  volume. 

719 


720  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

If  I  name  some  of  those  principles,  they  seem  commonplace  enough, 
and  men  will  say,  perhaps,  that  they  have  them  always  in  mind;  but 
such  is  not  by  any  means  the  conclusion  of  observers  who  watch  the 
detail  of  work  in  our  great  hospitals. 

The  most  important  lesson  which  a  surgeon  has  to  leani  is  to  estimate 
the  patient's  general  condition.  I  put  that  as  essentially  above  any 
question  of  therapeutics.  That  matter  of  the  general  condition  is  a 
very  large  part  of  diagnosis.  One  has  various  routine  questions  which 
one  asks  in  a  perfunctory  fashion:  the  patient's  age,  birthplace,  resi- 
dence, occupation,  family  history,  and  previous  condition  of  health, 
and  in  some  sort  one  leams  the  answers — but  those  answers  are  not 
idle  babble:  the}^  have  a  very  real  bearing  on  the  matter  in  hand.  In 
a  surgical  clinic  one  is  altogether  too  prone  to  assume  that  eveiy  case 
is  an  operative  one  pure  and  simple,  and  one  looks  no  further.  This 
is  one  of  the  deplorable  results  of  specialism  gone  mad.  In  the  old 
days  it  was  required  of  the  surgeon  that  he  have  a  good  practical 
working  knowledge  of  general  medicine.  Operations  were  a  last  resort; 
John  Hunter  and  Liston  told  their  classes  that  the  knife  was  an  oppro- 
brium, and  should  be  used  when  all  other  means  failed.  Of  course, 
that  extreme  view  has  long  ceased  to  prevail — modified,  first,  by  the 
introduction  of  anesthetics  and  later  by  the  development  of  asepsis. 
Indeed,  for  long  the  pendulum  was  swinging  the  other  way,  when  the 
knife  was  deemed  the  only  reliable  measure.  Now,  again,  thanks  to 
increased  knowledge,  we  are  appreciating  that  there  are  other  resources. 

Every  one  of  those  data  which  the  clinical  clerk  takes  do-\^ai  by  rote 
may  be  of  the  greatest  importance.  Age  may  rule  out  man}-  things, 
such  as  cancer,  arteriosclerosis,  and  the  like;  the  place  of  birth  and 
the  race  may  suggest  tuberculosis  or  malaria,  as  may  the  residence. 
The  other  day  I  saw  a  case  of  anthrax  of  which  the  diagnosis  was  ren- 
dered probable  by  the  patient's  surroundings;  there  are  numerous 
occupation  diseases — lead-poisoning  and  "  housemaid's-knee "  will  at 
once  occur  to  the  reader.  That  matter  of  family  history  or  hereditary 
tendency  is  important,  in  spite  of  the  new  light  we  are  constantly 
getting  on  the  whole  question  of  etiology;  and  especially  the  patient's 
previous  condition  of  health  is  to  be  studied. 

Take,  for  example,  a  patient  who  illustrates  in  his  o^^^l  person  many 
of  the  points  w'e  are  considering.  He  is  a  young  man.  His  age  is 
twenty-three.  He  is  of  American  parentage  and  of  vigorous  stock. 
He  was  born,  reared,  and  now  works  in  a  town  which  is  notorious  for  its 
unwholesome  location,  being  low-lying,  ill  drained,  and  inadequately 
supplied  with  water.  The  young  man  is  assistant  to  a  sewer  contractor, 
and  spent  most  of  one  summer  overseeing  a  gang  of  men  engaged  in 
laying  drains.  In  September  he  became  ill  with  typhoid  fever,  as 
appears  from  his  phj'sician's  statement  and  the  story  he  himself  tells. 
Typhoid  was  epidemic  in  his  town.  Recovering,  after  an  illness  of 
some  two  months,  he  returned  to  work.  After  an  interval  of  six  months 
he  was  seized  with  acute  pain  in  the  region  of  the  right  shoulder. 
The  pain  increased,  and  became  severe — of  a  boring,  throbbing,  agoniz- 


THE   EXAMINATION   AND   STUDY   OF   CASES  721 

ing  character.  The  patient  looks  hke  a  sick  man.  He  is  flushed, 
with  a  coated  tongue,  the  bowels  are  constipated,  the  urine  is  scanty 
and  high  colored.  The  man  supports  his  arm  in  his  hand;  he  favors 
it,  as  we  say,  and  is  evidently  in  great  suffering.  On  examining  him 
we  find  his  pulse  to  be  bounding  and  rapid,  with  a  rate  of  116,  and  a 
blood-pressure  recorded  as  190  by  the  Riva-Rocci  apparatus. 

AVhen  we  handle  the  arm  we  find  some  slight  swelling  and  a  sense 
of  bogginess  about  the  shoulder-joint;  but  the  joint  itself  is  not  especially 
tender  on  pressure,  and  the  patient  seems  to  refer  his  pain  rather  to  the 
head  of  the  humerus. 

Here  is  a  very  definite  picture.  On  the  history  alone  one  should 
be  able  to  make  a  correct  diagnosis.  The  man  is  obviously  the  victim 
of  an  acute  infectious  process.  He  has  been  for  long  exposed  to  un- 
sanitary conditions,  and  he  has  recently  had  typhoid  fever.  The 
leukocytosis  in  his  case  is  40,000,  and  the  temperature  104°  F. 

What  are  we  to  conclude  from  this  collection  of  signs  and  symptoms? 
There  are  but  two  processes  which  suggest  themselves  at  once — an 
acute  infectious  arthritis  (articular  rheumatism)  and  an  acute  osteo- 
myelitis. To  distinguish  between  these  two  conditions  is  of  the  utmost 
importance.  In  the  two  diseases  the  signs  and  symptoms  are  in  many 
respects  identical,  but  we  have  two  points  as  guides:  the  bone  rather 
than  the  joint  is  the  seat  of  pain,  and  the  patient  has  recently  had 
typhoid  fever.  We  know  that  acute  general  infections  are  frequent 
precursors  of  osteomyelitis,  and  we  are  justified  in  concluding  that  we 
are  dealing  here  with  that  process.  A  correct  decision  is  urgent.  Such 
a  case  should  be  admitted  to  the  hospital  at  once,  and  the  shaft  of  the 
humerus  opened  and  drained,  when  doubtless  he  wiU  recover  with  a 
useful  arm.  A  few  days'  or  even  hours'  delay  might  mean  for  him  a 
systemic  infection,  septicemia,  and  death. 

To  take  up  the  thread  of  our  main  topic  again:  there  is  that  inde- 
finable thing  we  call  the  patient's  general  condition.  One  cannot 
too  soon  begin  to  bear  that  thought  constantly  in  mind.  Sir  Benjamin 
Brodie  used  to  say  that  he  could  often  make  a  diagnosis  by  the  smell 
of  the  patient's  bedroom.  It  is  unnecessary  for  the  modern  student 
to  know  such  shrewd  tricks  as  that,  but  he  must  learn  to  put  all  senses 
into  action.  He  goes  to  the  clinic  fresh  from  his  laboratory  studies. 
Hitherto  he  has  learned  the  use  of  the  sense  of  sight  only,  now  he  must 
cultivate  his  hearing,  touch,  and  smell  even,  like  old  Sir  Benjamin; 
and  he  must  come  gradually  to  appreciate  that  nebulous  aura  of  physi- 
cal condition  which  every  man,  sick  or  well,  carries  with  him.  When 
to  these  things  he  adds  those  instruments  of  precision,  the  uses  of  which 
he  has  learned,  there  will  be  an  accuracy  and  finalitj^  to  his  decisions 
which  were  impossible  for  the  ancient  men. 

One  concludes  from  what  I  have  said  that  a  competent  surgeon  must 
be  a  very  thoroughly  equipped  all-round  man.  Exactly  that  is  my 
meaning.  One  must  study  general  medicine  as  well  as  surgery,  and 
must  follow  carefully  both  sets  of  clinics.  There  was  a  time,  fifty 
years  ago  and  less,  when  all  surgeons  were  general  practitioners.    Then, 

46 


22  MINOR   SUKGERY — DISEASES    OF   STRUCTURE 


/J^ 


with  the  development  of  specialties,  came  a  natural  antl  proper  narrow- 
ing of  the  surgeon's  field.  For  years  we  devised  new  operations,  we 
attacked  organs  previously  regarded  as  inaccessible,  we  learned  and 
perfected  a  new  practice  and  a  new  technic.  It  has  come  about  with 
this  development  of  our  branch  of  the  art  of  medicine  that  many  dis- 
eases as  well  as  organs  have  become  the  surgeon's  own, — his  own  in 
part  at  least, — diseases  and  organs  with  which  he  never  thought  to 
tamper  a  few  j^ears  ago.  So  again  it  is  becoming  apparent  that  he  must 
be  familiar  with  a  great  variety  of  processes  which,  a  few  years  ago,  con- 
cerned him  little  if  at  all.  In  that  second  stage  of  the  surgeon's  develop- 
ment he  was  often  little  more  than  a  thorough  anatomist  and  a  clever 
handicraftsman.  We  have  outgrown  that  stage.  We  now  realize  that 
tke  surgeon  must  know  and  be  ready  to  apply  the  principles  of  physi- 
ology, chemistry,  pathology,  and  bacteriology,  as  well  as  those  of  anat- 
omy and  physics.  He  deals  with  almost  every  known  disease  and 
with  every  organ  of  the  body.  He  must  be  familiar  with  the  stmcture 
and  function  of  those  organs,  the  nature  of  their  disease  processes,  and 
the  appropriate  methods  of  treatment,  if  he  is  to  put  to  their  best 
and  proper  uses  the  therapeutic  measures  with  which  he  is  especially 
equipped.  He  must  not  stand  idly  by  until  his  medical  confrere  says 
"  cut."  He  must  cut  when  the  time  comes,  of  course,  but  must  use 
his  own  matured  judgment  to  sustain  the  advice  of  his  colleague. 

Before  now,  following  the  old  blind  method,  the  chest  has  been 
opened  for  empyema  when  no  pus  was  there;  the  appendix  has  been 
removed  when  typhoid  fever  was  the  cause  of  the  symptoms,  and  the 
gall-bladder  has  been  opened  for  the  cure  of  lumbricoid  worms.  I  have 
even  known  a  colleague  to  scoff  at  a  surgeon  who  used  a  stethoscope, 
and  to  look  upon  a  microscope  as  an  instrument  outside  of  his  ken. 

A  surgeon's  duty  is  the  treatment  of  disease  by  proper  and  recog- 
nized surgical  measures;  but  he  should  have  a  sound  knowledge  of  all 
disease  as  well,  recognizing  his  ovm  limitations;  and  while  his  medical 
colleague  is  at  work  with  his  proper  investigations  and  remedies,  the 
surgeon  should  stand  by,  waiting  to  be  called  upon  for  the  employment 
of  his  own  peculiar  skill. 

Given  then  the  particular  case,  such  as  that  of  the  man  with  osteo- 
myelitis :  One  has  looked  the  ground  over,  has  ascertained  the  gravity 
of  the  general  condition,  and  now  turns  his  attention  to  the  special 
lesion  under  consideration.  That  lesion  is  in  the  arm  near  the  shoulder- 
joint;  and  without  further  doubt  one  makes  the  diagnosis  and  recom- 
mends appropriate  treatment.  But  take  another  patient  as  a  foil  to  the 
first.  He,  too,  is  a  young  man — not  more  than  thirty-five;  his  previous 
condition  of  health  is  unimportant,  and  he,  too,  has  a  disease  near  the 
shoulder-joint.  It  is  in  the  nature  of  a  swelling  or  tumor,  and  he  has 
had  it  for  some  fifteen  years.     It  is  a  chronic  process,  therefore. 

When  we  see  a  swelling,  there  are  two  questions  which  should  suggest 
themselves  at  once:  Is  this  an  inflammatory  process  or  is  it  a  neoplasm 9 
For  the  purpose  of  practical  exclusion  i*un  over  rapidly  the  old  formula 
which   applies  to  acute  inflammations — Is  there  pai7i,  heat,  redness, 


THE   EXAMINATION    AND    STUDY   OF   CASES  723 

sircJli7ig,  and  impairment  of  function?  In  this  case  all  these  are 
absent  save  swelling;  moreover,  this  is  a  chronic  process.  Then  call 
up  the  other  familiar  formula  which  applies  to  a  swelling — What  is  its 
exact  location,  size,  shape,  color,  consistency?  One  must  have  these  two 
formuUr  always  in  mind.  This  swelling  has  none  of  the  characteristics 
of  infianmiation,  and  the  patient's  general  condition  is  excellent.  There- 
fore it  is  probal^l}^  a  neoplasm  and  of  a  benign  type.  It  is  situated 
just  below  the  acromion  process,  over  the  middle  of  the  deltoid  muscle. 
It  is  about  the  size  of  a  small  orange;  it  is  spheric  and  uniform  in 
outline;  its  color  does  not  differ  from  that  of  the  surrounding  .skin; 
it  is  soft,  rather  gelatinous  to  the  touch,  but  it  does  not  distinctly 
fluctuate.  It  is  subcutaneous,  movable,  not  adherent  to  the  skin,  and 
the  adjacent  glands  show  no  metastasis. 

Observe  carefully  the  method  of  approaching  the  patient  and 
handling  the  Httle  mass.  See  that  he  sits  or  stands  at  ease  before  you, 
with  a  good  strong  light  upon  him,  while  your  own  back  is  turned  to 
the  window.  Gain  his  confidence  by  assuring  him  that  you  do  not 
expect  to  hurt  him.  He  will  then  sit  relaxed  and  will  not  shrink  or 
grow  tense  at  your  touch — an  important  desideratum.  Now  pass 
your  extended  palm  gently  over  the  tumor,  once  or  twice.  In  that  way 
you  will  gain  a  great  deal  of  information,  and  if  the  parts  are  sensitive, 
you  will  give  no  pain.  The  tactus  eruditus  does  not  belong  to  the  heavy- 
handed  surgeon.  One  cannot  too  strongly  urge  upon  the  student 
the  great  advantage  and  importance  of  gentleness.  Patients  recognize 
it  at  once.  The  patient  knows  when  he  is  being  handled  by  a  man 
who  knoW'S  his  business.  The  reputation  of  being  rough  or  brutal  never 
helps  a  surgeon. 

See  the  thoughtless,  inexpert  man  plunge  at  a  painful,  sensitive 
region  as  though  he  were  kneading  dough!  One  can  teU  the  neophyte 
at  once  by  his  roughness.  The  gentle  outspread  palm  and  fingers  of 
the  examiner  are  extremely  sensitive  to  tactile  impressions  and  can 
be  educated  to  a  rare  facility.  It  is  seldom  necessary  to  prod  and 
poke  with  the  finger-tips. 

Passing  one's  hand  over  the  tumor  in  question,  one  readily  defines 
its  outline,  its  extent,  its  density,  its  mobility,  and  notes  the  absence 
of  sensitiveness.  Now  one  may  pick  it  up  in  the  finger-tips  and  de- 
termine, if  necessary,  its  lack  of  fluctuation  and  the  depth  of  its  attach- 
ments. 

That  is  the  whole  story.  We  have  the  list  of  benign  tumors  in 
mind  and,  running  over  them,  we  see  at  once  that  this  must  be  a  fatty 
tumor  or  lipoma.  After  all,  it  makes  Httle  difference  what  we  call  it. 
The  method  of  examination  concerns  us  at  present,  and  if  one  has 
learned  to  take  a  broad  view  of  the  case,  to  approach  it  without  rush 
or  flurry,  and  to  observe  accurately  those  few  important  details  of 
w^hich  I  have  written,  the  giving  a  name  and  the  assigning  treatment 
will  naturally  and  readily  follow\ 


724  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

INCISED   WOUNDS 

Twenty  years  ago  Sampson  Gamgee  published  in  London  one  of 
the  best  books  in  English  that  is  known  to  me  on  the  treatment  of 
wounds  and  fractures. 

After  describing  in  some  detail  the  pathologic  conditions  which 
arc  met  with  in  these  phenomena,  he  goes  on  to  lay  down  the  cardinal 
principle  of  support  for  the  injured  part,  and  this  he  recognizes  as  the 
one  essential  in  the  therapeutics  of  traumatic  surgery. 

We  shall  have  much  to  say  as  to  the  meaning  of  that  word  "  support." 
In  the  time  of  Gamgee's  writing  the  word  asepsis,  in  the  modem  sense, 
had  hardly  been  invented;  but  it  has  now  come  not  altogether  justly 
to  usurp  the  honors  of  surgical  support;  for  in  the  consideration  of 
all  wounds,  whether  of  the  soft  or  hard  parts,  in  which  there  has  been  any 
sort  of  disturbance  of  continuity,  you  should  have  constantly  in  mind 
that  that  severed  continuity  must  prompth'  be  restored;  that  those 
restored  parts  must  be  absolutely  immobilized  and  supported,  and  that 
this  work  must  be  done  under  aseptic  conditions. 

Take  a  simple  case  in  point.  The  patient  is  a  tinsmith,  thirty  years 
old,  sound  and  vigorous.  About  two  hours  ago,  A\-hile  at  his  work,  he 
cut  through  the  skin  and  fascia  of  his  palm,  leaving  a  clean,  straight 
wound,  extending  about  three  inches  across  the  hand. 

Let  us  see  how  we  may  apply  our  two  principles,  support  and  asepsis. 
We  must  regard  what  we  have  to  do  as  a  surgical  operation.  The  whole 
field  of  the  wound — and  in  this  case  the  field  is  the  man's  hand — is 
sterilized,  so  far  as  may  be — by  a  thorough  scmbbing  with  soap  and 
water,  followed  by  immersion  in  chlorinated  soda  and  wiping  with 
cotton  sponges  dipped  in  75  per  cent,  alcohol.  The  hand  is  then  im- 
mersed for  two  minutes  in  an  alcoholic  solution  of  bichlorid  of  mercury, 
1  :  3000.  The  hand  and  arm  are  then  wrapped  in  a  clean  steamed 
towel,  and  the  patient  sits  before  the  surgeon  with  his  arm  outstretched, 
palm  upward,  upon  the  table.  Meanwhile  the  surgeon  has  cleaned  his 
own  hands  with  soap  and  water  and  alcohol,  and  has  put  on  i-ubber 
gloves  which  have  been  sterilized  by  boiling.  I  have  gone  into  this 
matter  in  some  detail,  because  details  in  asepsis  are  the  sine  qua  non  of 
successful  surgery. 

Let  us  now  examine  the  wound.  We  must  be  sure  always  that  no 
foreign  substance  remains  in  its  depths,  and  in  this  case  we  find  none. 
As  the  wound  is  held  open,  we  see  the  extensive  tear  in  the  palmar 
fascia.  One  is  scrupulous  to  close  this,  for  by  so  doing  we  hasten  the 
restoration  of  function.  It  is  closed  with  three  intermpted  catgut 
stitches,  and  with  the  use  of  the  curved  needle  rather  than  the  straight 
one.  There  remains  the  skin-wound  of  the  palm,  which  lies  together 
without  gaping.  The  severed  edges  are  dusted  with  a  simple  drying 
powder,  aristol;  a  bit  of  crepe  lisse  laid  across  and  secured  with  collo- 
dion further  supports  them.  One  then  applies  a  bit  of  absorbent 
cotton  also  held  do^^•n  with  collodion  about  the  edges,  forming  what 
we  call  the  "  cocoon  dressing." 


INCISED   WOrXDS  725 

Now  one  would  say  that  sufticient  has  been  done  to  assure  a  prompt 
and  sound  healing  by  the  "first  intention";  but  observe  that  the 
second  only  of  our  cardinal  principles  has  been  applied  up  to  this  point. 
A  reasonably  accurate  asepsis  has  been  provided;  why  is  not  that  suf- 
ficient, and  why  do  we  go  on  to  apply  the  first  principle — support  and 
immobihzation?  A  very  simple  experiment  on  one's  own  fingers  will 
illustrate  the  reason.  If  I  prick  my  finger  sharply,  tie  an  elastic  band 
around  it,  and  let  it  hang  down  for  a  few  minutes,  I  find  that  the  whole 
finger  shortly  will  throb  painfully,  and  the  pricked  wound  will  smart 
and  ache.  Now  I  remove  the  nibber  band,  place  my  hand  upon  the 
opposite  shoulder,  and  hold  it  there  steadily;  I  experience  quickly 
relief  and  a  sense  of  comfort.  The  series  of  phenomena  which  I  have 
experienced  are  not  dissimilar  from  what  will  occur  in  this  man's 
wounded  palm.  Were  we  to  leave  his  hand  unprotected,  except  for 
the  cotton  and  collodion,  he  would  naturally  swing  it  at  his  side.  Al- 
most at  once  the  process  of  repair  will  have  begun — there  will  be  the 
inevitable  increased  blood-supply  in  the  wounded  parts,  a  certain 
amount  of  exudation  will  go  on,  the  venous  circulation  will  be  slightly 
impeded,  and  all  these  conditions  will  be  accentuated  by  hypostasis  if 
his  hand  hangs  down;  in  other  words,  the  reparative  process  will  be 
interfered  with. 

Hitherto  surgeons  have  been  able  'to  devise  no  means  of  disinfecting 
thoroughly  the  skin.  The  epidermis  may  be  scnibbed  and  treated  with 
chemicals  until  it  is  fairly  free  from  micro-organisms,  but  the  corium 
cannot  be  touched  by  such  methods,  and  in  the  corium  normally  there 
are  to  be  found  pathogenic  organisms,  mostly  the  Staphylococcus 
epidermidis  albus.  You  must  bear  in  mind,  too,  that  in  the  aseptic 
operations  of  surgery  we  have  three  principal  sources  of  infection  to 
consider:  First,  the  instruments;  second,  the  dressings  and  suture 
materials;  and,  third,  the  skin,  whether  of  patient  or  operator.  At 
the  present  time  we  have  advanced  so  far  that  we  have  eliminated 
the  first  two  sources.  Instniments  properly  boiled  carry  no  organisms; 
dressings  and  suture  materials  properly  steamed  and  prepared  are  sterile. 
So  we  come  to  the  third  source,  the  skin.  Even  that  to  a  larger  extent 
may  be  mled  out,  for  we  now  wear  aseptic  gloves, — surgeons  and  all 
assistants, — so  that  we  are  left  with  the  patient  himself  as  the  one 
most  important  carrier  of  possible  infection;  and  after  the  most  scrupu- 
lous care  in  preparation,  the  patient's  skin  must  carry  in  its  deep  parts 
pathogenic  organisms,  as  we  have  seen.  One  asks.  Why  do  not  these 
bacteria  always  produce  sepsis?  Because  to  do  so  they  must  be  present 
in  great  numbers,  or  else  they  must  fall  upon  suitable  soil,  or  both. 

One  need  not  review  here  the  well-kno'U'n  fact  that  in  varj^ing 
degrees  patients  carry  in  their  own  tissues  disease-resisting  elements; 
suffice  it  only  to  remind  the  reader  that  organisms  which  will  grow  and 
multiply  in  and  infect  one  man  will  fall  harmless  upon  another;  and 
here  is  the  practical  point,  that  in  a  great  many  cases,  by  appropriate 
treatment,  one  may  help  to  bring  nearer  to  immunit}',  and  may  fortify 
the  resisting  powers  of  an  individual  patient. 


726  MINOR   SURGERY — DISEASES    OF   STRUCTURE 

So  it  is  practically  in  the  patient's  own  skin,  and  there  chiefly,  that 
we  must  look  for  a  source  of  sepsis. 

What  became  of  the  organisms  at  the  time  our  patient  received  his 
wound?  Some  of  them  were  undoubtedly  carried  into  the  deeper 
parts,  some  of  them  still  remain  on  the  cut  edges,  and  others  will  be 
foi'ced  into  the  wound  itself  and  into  the  general  circulation  during 
the  earl}'  hours  of  repair.  Now  this  man's  hand  has  been  n^ieved  of 
a  large  number  of  organisms  by  the  antiseptics  we  have  applied.  We 
must  strive  to  render  the  deep  parts  of  the  field  infertile.  No  better 
medium  exists  for  the  growth  of  organisms  than  a  stagnant  or  sluggish 
blood-sup}:»ly,  and  that  condition  exists  to  perfection  \\-hen  we  leave 
the  man's  hand  hanging  at  his  side.  So  we  place  it  high  upon  his  chest 
and  secure  it  in  a  sling. 

We  have  now  provided  for  asepsis  and  elevation.  It  remains  for  us 
to  secure  surgical  ini mobilization. 

If  we  leave  the  man's  hand  iniconfined  except  by  the  light,  support- 
ing sling,  there  will  be  nothing  to  prevent  his  withdrawing  it  from  the 
sling,  and  there  will  be  nothing  to  prevent  his  using  the  hand  and  fingers, 
even  if  they  be  elevated. 

Here,  again,  one  asks.  What  harm  can  possibly  result  from  such  use? 
We  have  conceived  of  an  exudation  essential  to  the  healing  process  in 
the  palm;  we  have  conceived  of  an  increased  flow  of  blood  to  the  part; 
we  can  further  see  how  the  support  of  the  arm  has  improved  the  venous 
circulation,  and  it  takes  very  little  imagination  to  understand  how  the 
action  of  the  muscles  dragging,  pulling,  and  contracting  may  well  keep 
up  an  irritation  W'hich,  superadded  to  the  other  conditions,  will  permit 
of  a  bacterial  activity  and  initiate  a  sepsis. 

These  are  simple  conceptions,  but  they  illvistrate  a  condition  which, 
after  all,  is  simple  enough;  again  we  come  back  to  our  point  and  say 
that  the  one  thing  left  and  needful  for  the  repair  of  this  man's  wound  is 
immobilization. 

Perfect  immobilization,  in  the  surgical  sense,  is  far  from  being  the 
simple  thing  one  might  suppose.  It  is  not  readily  attained;  and  it 
cannot  be  attained  without  giving  careful  thought  to  the  anatomy  of 
the  parts.  Take  the  instance  of  the  man's  wounded  hand.  What 
are  the  important  structures  which  go  to  make  up  the  anatomy  of  the 
palm  and  adjacent  parts?  Obviously,  they  are  the  skin  and  fascia,  the 
underlying  tendons  and  muscles,  and  the  bones.  We  cannot  keep 
the  wound  in  a  state  of  surgical  rest  unless  we  immobilize  the  adjacent 
stmctures,  and  that  means  that  we  must  tie  up  the  muscles  of  the  part. 
Those  muscles  are  the  extensors  and  flexors  of  the  hand,  and  their  origin 
is  about  the  condyles  of  the  humerus  and  in  the  forearm,  a  fact  elemen- 
tary and  obvious  enough,  but  surpiisingly  often  overlooked.  So  we 
must  bandage  carefully  and  restrain  the  movements  of  the  forearm. 
Observe  now  a  point  which  we  must  emphasize  repeatedly.  Never 
apply  for  immobilization  a  bandage  close  to  the  skin  or  over  a  thin 
intervening  pad.  Leani  always  to  use  elastic  covjpressioji.  We  cover 
the  patient's  hand  and  forearm  with  six  or  eight  layers  of  sheet-wadding 


INCISED    WOUNDS  727 

— an  elastic,  very  slightly  absorbent  material,  which  will  not  become 
caked  and  matted  with  perspiration.  Between  alternate  layers  of  the 
wadding  place  four  strips  of  moistened  mill  board — two  laid  straight 
down  the  arm  and  two  twisted  spirally  about  it.  These  harden  as  they 
dry,  and  lend  an  added  stiffness  and  elasticity  to  the  dressing.  So  far 
the'  application  looks  cumbersome  and  unwieldy,  but  with  this  cotton 
roller  we  now  carefully  and  snugly  bind  the  whole  into  place.  Pull 
the  bandage  tight,  greatly  diminishing  the  bulk  of  the  dressing,  so  that 
when  completed  it  appears  to  be  of  moderate  proportions.  If  you 
handle  the  completed  dressing  you  find  that  it  is  quite  elastic  to  the 
touch,  and  that  it  exerts  everywhere  a  perfectly  equable  compression. 
It  controls  absolutely  the  muscles ;  no  movement  can  go  on  underneath 
it,  yet  it  is  extremely  comfortable.  It  is  tight,  but  it  does  not  constrict. 
By  its  firm  contact  everywhere  with  the  underlying  parts  it  moderates 
and  controls  the  circulation,  but  it  does  not  occlude  it.  Here  we  have 
illustrated  on  a  large  scale  the  principles  of  compression  which  one 
applies  when  he  seizes  and  compresses  gently  and  brings  comfort  to  his 
sore  thumb,  which  throbs  and  aches  with  the  beginning  of  a  "  nm- 
round."  Thus  one  sees  employed  the  four  remedies  which  one  must 
learn  to  apply  in  the  dressing  of  all  wounds:  asepsis,  elevation,  immo- 
bilization, and  compression,  and  the  last  three  imply  swpporf — remedies 
which  may  be  modified  in  degree  often  to  suit  special  conditions — 
perhaps  they  are  employed  with  oversciTipulous  care  in  this  particular 
case;  but  they  are  always  important,  always  to  be  borne  carefully  in 
mind;  to  become  as  much  a  part  of  one's  instinct  and  training  as  that 
antiseptic  conscience  of  which  we  have  heard  tell. 

Consider  next  two  cases  which  illustrate  the  results  of  proper  and 
improper  treatment.  A  lad  received  a  ragged,  four-inch  wound  of  the 
wrist  from  falling  on  a  broken  bottle  some  ten  days  ago.  The  skin  cut 
one  sees,  but  more  than  that,  the  superficialis  volse  artery  and  one  tendon 
of  the  flexor  sublimis  digitorum  were  severed.  When  brought  to  the 
hospital,  about  three  hours  after  the  accident,  the  boy's  arm  was  found 
tied  up  tightly  with  a  knotted  handkerchief, — as  a  tourniquet, — the 
wound  gaping  and  ugly  looking,  where  cobwebs — a  favorite  domestic 
remedy — had  been  smeared  over  it,  blood  still  oozing  from  the  artery, 
and  the  whole  hand  livid,  swollen,  and  painful. 

The  patient  was  laid  on  the  operating  table,  the  handkerchief  re- 
moved, the  arm  elevated  in  the  air  and  supported  by  an  assistant  for 
about  five  minutes,  when  the  bleeding  was  found  to  have  ceased,  the 
swelling  to  have  subsided,  and  the  hand  to  be  normal  looking  and  pain- 
less. Then  the  whole  arm  and  hand  were  cleaned  and  disinfected — 
washed,  scrubbed,  and  soaked,  not  dabbed  at  and  mopped  over  with  a 
futile  corrosive  sponge. 

The  two  ends  of  the  cut  vessel  were  secured  and  tied  with  catgut, 
the  severed  tendon  was  united  by  fine  silk  stitches,  the  skin-edges  care- 
fully and  accurately  approximated  with  four  silver  wire  points, — which 
I  prefer  in  the  case  of  these  ragged  cuts  of  the  wrist, — and  the  hand 
and  arm  put  up  in  the  manner  demonstrated  in  the  case  of  the  tin- 


728  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

smith.  In  this  case,  of  course,  the  wrist  was  secured  in  a  position  of 
slight  flexion  to  reHeve  tension  on  the  severed  tendon.  After  the  first 
dressing  the  patient  felt  perfectly  comfortable;  his  temperature  was 
normal  and  his  bodily  functions  undisturbed.  Twice  during  this  time 
an  atlditional  tight  bandage  was  applied  over  the  dressing,  which  had 
become  somewhat  loosened. 

The  apparatus  being  removed,  we  observe  the  entire  limb  to  be 
pale  and  shrunken.  That  is  as  it  should  be.  The  hand  looks  thin  and 
normal;  the  fingers  are  flexible;  the  wound  is  a  simjjle  red  line — not 
puffy,  not  tender,  not  painful.  The  old  cocoon  dressing  shows  a  little 
dry,  blood-stained  exudate.  One  removes  carefully  the  silver  stitches 
which  have  admirably  supported  the  irregular  skin-edges,  and  the 
wound  is  found  practically  healed.  Of  course,  there  is  more  to  the  case. 
That  tendon  wound  will  be  slow  in  healing,  and  the  hand  must  be 
protected  and  supported  for  some  weeks  on  that  account,  but  so  far  as 
our  simple  incised  wound  is  concerned,  it  need  trouble  us  no  more.  The 
dressing  was  dry  and  it  was  infrequently  renewed.  Napoleon's  famous 
surgeon,  Baron  Larrey,  was  the  great  exponent  of  that  method  a  hun- 
dred years  ago.  Read  what  he  says  in  his  delightful  "  Memoirs"  on  the 
subject  of  infrequent  dressings. 

Turn  your  attention  to  a  man  whose  story  is  not  so  happy.  He 
is  a  postman.  Five  days  before  we  saw  him  he  received  a  cut  on  the 
back  of  the  left  forearm,  being  struck  by  a  piece  of  falling  wintlow-giass. 
The  cut  was  about  six  inches  long.  Only  the  skin,  thick  fascia,  and 
some  fibers  of  the  muscles  of  the  extensor  group  were  cut.  There  was 
little  bleeding.  The  wound  was  cleaned  and  covered  in  with  the  greatest 
care,  but  a  supporting  bandage  and  sling  were  omitted,  at  the  man's 
request,  as  he  said  they  would  interfere  with  him  and  that  he  would 
be  careful  not  to  use  his  arm. 

On  the  sixth  day  he  reports  for  the  first  time  after  five  days  of 
active  running  about,  swinging  the  arm  at  his  side.  We  see  the  state 
of  his  wovmd  and  compare  it  with  that  of  the  lad  with  the  severed 
tendon.  In  the  postman's  arm  is  a  distinctly  reddened  area,  extending 
for  an  inch  all  about  the  cut,  the  edges  of  which  are  infected  and  slightly 
swollen.  We  remove  one  stitch  and  find  it  is  followed  by  a  drop  of  pus. 
The  man  says  that  the  wound  has  ached  for  the  past  two  days,  and 
that  he  has  felt  "feverish"  and  uncomfortable.  His  temperature  is 
99.4°  F.  The  arm  has  not  the  shrunken,  cool,  almost  anemic  look 
that  we  saw  in  the  last  case,  but  is  distinctly  warm  and  full.  Fortu- 
nately, no  great  damage  has  been  done  as  yet.  By  appropriate  treat- 
ment the  initial  sepsis  may  be  checked,  but  the  man  has  delayed  his 
convalescence  by  several  days,  and  we  have  a  series  of  troublesome 
dressings  to  occupy  us. 

So  much  for  the  three  cases  of  simple  incised  wounds.  They  have 
been  striking  types  and  have  told  their  own  story,  yet  one  must  qualify 
that  story  in  a  few  words. 

AU  incised  wounds  carefully  cleaned  and  put  up  with  compression 
and  elevation  do  not  heal  promptly,  nor  do  all  the  wounds,  lacking  that 


SIMPLE  OR  CLOSED  FRACTURES  729 

support,  become  septic.  If  there  is  any  one  thing  true  of  surgical 
thcM'ai)euti('S,  it  is  that  there  is  in  it  no  pkice  for  dogma.  Beware  of 
the  surgeon  or  physician  who  says,  thus  and  thus  shall  it  be  done  and 
not  othei-wise.  Such  precepts  make  of  surgery  an  exact  science,  which 
it  is  not,  and  the  men  who  presume  to  apply  to  it  iron-clad  rules  have 
to  change  their  dogma  from  year  to  year. 

But  there  are  broad  general  principles  which  the  student  will  find 
safer  than  dogma.  Two  of  those  broad  principles  we  have  studied — 
asepsis,  rigid  asepsis,  must  be  the  sheet-anchor  in  all  surgical  work; 
physiologic  support,  immobilization,  compression,  next  after  asepsis, 
are  essential  for  the  safe  and  prompt  healing  of  the  great  majority  of 
wounds. 

SIMPLE  OR  CLOSED   FRACTURES 

Percival  Pott  fell  down  in  a  London  street  and  broke  his  leg  a 
hundred  and  thirty  years  ago.  He  got  well  and  wrote  about  it,  and 
since  then  surgeons  have  known  more  about  fractures  than  they  knew 
before.  Pott's  famous  fracture  marks  an  era  in  our  annals.  From  that 
time  to  the  present  our  knowledge  of  fractures  has  been  growing  more 
definite,  until  to-day,  with  x-ray  plates  for  aid  in  diagnosis,  there  is  small 
excuse  for  any  surgeon's  going  far  astray.  Yet  men,  even  the  expert,  do 
go  astray.  Probably  there  is  no  class  of  cases  presented  to  us  which  is 
so  easy  of  misapprehension,  and  in  which  the  results  of  misapplied 
treatment  are  so  deplorable.  We  shall  not  now  consider  fractures  in 
detail,  but  glance  at  two  or  three  simple  cases  and  note  the  methods  of 
handling  them,  of  making  the  diagnosis,  and  applying  a  suitable  treat- 
ment. We  shall  regard  closed  fractures  only,  or,  as  they  are  more  com- 
monly called,  simple  fractures. 

The  analogy  between  lesions  of  the  soft  parts  and  of  bones  is  a  close 
one.  The  processes  of  repair  are  not  dissimilar,  and  the  rules  of  treat- 
ment do  not  diverge  greatly.  But  our  analogy  is  incomplete  in  one 
important  particular.  In  the  case  of  severed  soft  parts  union  will  take 
place  though  the  apposition  be  imperfect,  and  though  the  united  struc- 
tures themselves  be  dissimilar— with  a  delayed  result,  to  be  sure,  and 
with  more  or  less  impairment  of  function :  there  we  have  nature,  un- 
aided, working  out  her  faulty  solution  of  the  problem.  But  in  the  case 
of  a  broken  bone,  our  art  must  be  carefully  and  constantly  applied  if 
the  injured  member  is  to  be  restored  to  any  sort  of  usefulness. 

For  example,  take  the  case  of  a  boy,  sixteen  years  old,  who,  while 
running,  fell  against  a  curbstone  and  injured  his  forearm.  We  see  him 
supporting  the  damaged  limb  with  his  hand  and  complaining  bitterly 
of  pain  half-way  between  the  elbow  and  the  wrist.  Let  us  proceed  with 
our  examination  carefully  and  painlessly  to  him,  so  far  as  we  can. 

In  the  first  place,  the  patient's  clothes  are  stripped  off  to  the  waist, 
thus  allowing  of  easy  inspection — an  important  point.  In  removing 
the  various  garments,  slip  off  the  coat-sleeve  from  the  sound  side  first; 
then  the  injured  arm  can  be  uncovered  without  undue  straining.  Cut 
the  shirt  down  the  front  and  slip  it  off  as  you  would  a  coat. 


730  MINOR    SURGERY — DISEASES   OF   STRUCTURE 

Allow  both  his  arms  to  hang  down,  and  observe  any  differences  in 
them.  We  see  that  the  affected  arm  hangs  limp  and  motionless;  the 
boy  cannot  raise  it.  It  appears  slightly  swollen,  and  one  may  detect 
a  slight  backward  bowing.     So  much  for  inspection. 

Then  compare  the  two  ai'ms  by  measurement.  Observe  that  on  the 
sound  side  the  distance  from  the  tip  of  the  olecranon  to  the  ulnar 
styloid  is  ten  inches.  On  the  affected  side  it  is  nine  and  one-quarter 
inches.  Obviously,  there  is  a  shortening  of  the  bones;  that  means  frac- 
ture. Is  it  a  fracture  of  one  or  both  bones?  Of  both  certainly;  for  if 
the  ulna  alone  were  broken,  the  radius  would  act  as  a  splint  and  main- 
tain the  length  of  the  arm  wdth  little  if  any  shortening.  So  we  have 
concluded  that  we  are  dealing  with  a  fracture  of  both  bones  of  the 
forearm,  and  so  far  we  have  caused  not  the  slightest  pain.  It  remains 
to  locate  the  exact  seat  of  the  fracture.  Now  it  may  be  necessary  to  hurt 
the  patient  somewhat,  but  if  we  proceed  cautiously,  he  will  bear  it  well. 
It  is  best  to  employ  an  assistant — two  assistants  are  even  better.  The 
patient  sits  with  his  arm  extended  upon  a  table.  One  assistant  sup- 
ports the  elbow  firmly,  the  other  holds  steadily  the  lower  part  of  the 
forearm,  making  gentle  traction;  for  there  are  spasm  and  contraction 
of  the  bruised  muscles.  The  examiner  now  runs  his  hand  gently  up 
and  clown  the  arm  and  comes  at  once  upon  an  area  of  thickening,  about 
five  inches  above  the  wrist.  That  area  is  the  seat  of  fracture.  Grasp- 
ing the  arm  firmly  above  and  below  the  injury,  while  the  assistant 
continues  to  make  traction,  the  surgeon  molds  the  bones  into  position, 
reducing  the  overriding  where  the  distal  fragments  have  slipped  over 
and  behind  the  proximal.  While  so  molding,  the  operator  experiences 
that  sensation  of  grating  or  "crepitus"  of  which  we  hear  so  much. 
While  we  keep  up  the  traction  observe  that  the  arm  has  been  brought 
back  to  the  same  measurement  as  its  fellow.  If  the  spasm  had  been  very 
strong  and  reduction  of  the  fracture  impossible  without  causing  great 
pain,  we  should  have  given  the  patient  an  anesthetic. 

We  come  now  to  the  difficult  question  of  the  support  and  immo- 
bilization of  fractures.  As  John  Hunter  said,  "The  first  and  great 
requisite  for  the  restoration  of  injured  parts  is  rest."  Shall  we  employ 
our  cotton  rollers  and  mill-board  strips  with  elastic  compression?  That 
certainly  would  give  rest  to  the  parts,  and  it  has  at  times  been  used  with 
success  in  these  cases.  If  this  were  the  fracture  of  but  one  bone,  we 
should  use  that  dressing.  As  a  rule,  however,  its  very  elasticity  renders 
it  unsafe  when  we  need  extension  or  traction  to  keep  the  bones  from 
overriding  again.  There  are  innumerable  splint  materials,  from  plain 
strips  of  wood  to  molded  gutta-percha,  wood  fiber,  felting,  and  plaster- 
of-Paris.  The  first  of  these,  known  among  us  as  "splint  wood,"  and 
the  plaster-of-Paris  are  convenient  and  are  in  common  use.  I  shall 
use  splint  wood  in  this  case,  as  the  arm  will  probably  swell,  and  splints 
of  splint  wood  can  be  removed  easily  and  readjusted. 

There  remain  two  other  important  points  to  consider  before  we 
apply  the  dressing.  We  can  lay  it  dowTi  as  a  safe  general  mle  in  dealing 
with  all  fractures  of  the  long  bones  that  the  adjacent  joints  at  either 


SIMPLE    OR   CLOSED   FRACTURES  731 

extremity  nuist  be  immobilized,  otherwise  the  phiy  of  the  muscles  will 
not  be  liekl  in  check,  und  with  the  movements  of  the  joints  there  will 
be  a  constant  displacement  of  fragments.  Moreover,  without  immo- 
bilizing the  joints  the  required  extension  cannot  be  maintained.  In 
this  case  we  must  fix  the  elbow  and  the  wrist. 

The  second  point  is  that  with  fractures  of  both  bones  of  the  forearm 
and  the  possible  large  resulting  calluses  which  sometimes  form,  the 
position  must  be  such  as  to  keep  the  shaft  of  the  radius  as  far  as  possible 
from  that  of  the  ulna,  else  all  four  wounded  bone  surfaces  might  become 
united  in  a  common  callus,  and  future  rotation  be  impossible.  In 
supination,  wdth  the  palm  turned  upward,  the  shafts  are  well  apart; 
in  semipronation  they  are  somewhat  further  apart;  in  extreme  prona- 
tion they  are  thrown  close  together,  and  if  there  be  extensive  laceration 
of  soft  parts,  it  is  possible  even  for  the  distal  fragment  of  the  radius  to 
become  united  with  the  proximal  fragment  of  the  ulna. 

Applying  Splints. — In  the  present  case  we  have  the  arm  held 
firmly  in  semipronation  and  proceed  to  apply  the  splints — a  simple 
matter  now. 

The  splints  of  light,  thin  wood  should  be  a  quarter  of  an  inch  wider 
than  the  forearm.  The  posterior  splint  extends  from  three  inches  above 
the  fracture  to  the  metacarpophalangeal  joints;  the  anterior  splint 
from  the  same  point  of  the  forearm  to  the  middle  of  the  palm,  and  a 
large  crescentic  groove  is  cut  out  of  its  side  to  avoid  pressure  on  the 
thenar  eminence.  The  splints  are  carefully  padded  with  six  sheets  of 
w^adding,  with  extra  small  pads  on  the  anterior  splint  to  conform  to  the 
contour  of  the  wrist.  Then  an  "internal  angular"  splint  of  molded 
tin  is  similarly  prepared  to  support  the  elbow. 

WhUe  the  arm  is  held  steadily  by  an  assistant,  who  stands  on  the 
patient's- outer  side,  the  surgeon  applies  these  splints  and  fastens  them 
firmly  but  not  tightly  in  place  by  four-inch  adhesive  straps  passed  round 
one  and  a  half  times.  There  are  three  straps — one  about  the  proximal 
end  of  the  splints,  one  about  the  wrist,  and  one  about  the  palm,  em- 
bracing the  posterior  splint  only.  This  last  strap  is  very  important, 
as  by  its  firm  pull  on  the  posterior  splint  it  keeps  up  traction.  Then 
the  elbow  splint  is  applied  with  three  straps — one  at  each  end  and  one 
just  below  the  bend  of  the  elbow\  The  whole  we  cover  with  a  cotton 
roller,  snugly  put  on.  That  is  a  fairly  comfortable  dressing,  but  one 
must  still  be  on  the  lookout  for  trouble.  Keep  the  patient  in  sight  for 
half  an  hour,  and  see  that  there  is  no  return  of  pain  before  he  leaves 
the  hospital.  Increase  of  pain,  throbbing  pain,  especially  if  the  fingers 
become  swollen  or  blue,  means  that  splints  are  too  tight.  One  must 
remove  and  reapply  them.  Then  we  must  support  the  arm  in  a  com- 
fortable sling  before  sending  the  patient  out.  If  he  goes  from  the 
hospital  in  pain,  we  may  be  certain  that  he  will  suffer  greatly  before 
morning,  and  the  frequent  swelling  of  the  arm,  against  the  immovable 
splints,  may  give  rise  to  ugly  skin  sloughs. 

As  for  the  after-treatment — that  is  not  always  easy;  it  calls 
often  for  the  best  judgment  and,  w-hen  neglected,  may  lead  to  serious 


732  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

deformity.  Moreover,  forearm  fractures  not  uncommcnily  result  iu 
non-union,  and  against  that  we  must  guard. 

One  advantage  of  the  use  of  open  splints  is  that  they  are  easily 
removed  for  inspection  of  the  wound.  We  shall  ask  the  boy  to  return 
daily  for  three  days.  If  we  find  the  arm  painless  and  the  swelling  not 
conspicuous,  we  shall  have  him  wait  until  a  week  from  the  accident 
has  elapsed  before  changing  the  splints. 

Another  patient  has  a  similar  fracture  ten  days  old.  We  see  that 
on  removing  the  bandage  the  position  of  the  bones  appears  good,  the 
swelling  has  subsided,  and  the  plaster  straps  are  a  little  loose.  The 
splints  are  taken  off,  when  a  slight  callus  is  felt  over  the  seat  of  the  frac- 
ture. The  skin  is  shrunken  and  pale,  and  the  elbow^  and  wrist  are  moved 
with  some  pain  and  difficulty.  Here  is  an  opportunity,  if  we  wish  to 
help  the  union  and  hasten  convalescence,  to  do  a  piece  of  work  usually 
neglected,  but  work  for  which  the  patient  will  bless  us.  We  shall  call 
in  a  competent  masseur,  and  have  him  manipulate  the  elbow,  the  wrist, 
and  the  tissues  about  the  fracture  for  half  an  hour  every  day.  The 
arm  must  be  securely  held  on  a  firm  cushion  or  on  the  padded  table 
while  the  masseur  is  at  work.  He  kneads  the  muscles  about  the  joints, 
he  loosens  slight  adhesions,  he  restores  the  stagnant  lymphatic  circula- 
tion, he  stimulates  the  circulation  of  the  whole  arm,  and  by  thus  improv- 
ing the  nutrition  of  the  parts,  he  hastens  the  union  of  the  broken  bones. 
I  have  employed  massage  for  years  in  such  fracture  cases  as  have  come 
under  my  care,  and  am  constantly  impressed  with  its  advantages — 
in  the  hastening  of  repair,  in  the  early  restoration  of  function,  perhaps, 
best  of  all,  in  the  sense  of  w^ell-being  given  at  the  time,  and  in  the  feeling 
of  security  and  confidence  so  soon  as  the  patient  reaches  the  stage 
at  which  active  movements  begin  to  succeed  these  passive  ones.  Under 
the  old-fashioned  treatment  the  arm  was  like  a  prisoner  confined  for 
weeks  in  a  dark,  narrow  cell,  to  emerge  at  the  last,  pale,  timid,  spiritless, 
broken  down — who  must  wait  weeks  yet  before  his  proper  vigor  returns 
to  him.  With  massage  you  let  in  air  and  light  upon  your  captive;  his 
windows  are  throw^n  open  daily,  and  he  is  taken  for  a  brisk  walk,  as  it 
were,  about  the  prison  yard.  At  the  end  of  his  confinement  he  returns 
to  the  former  life  with  his  force  but  little  abated  and  his  zest  sharpened 
for  the  work  of  the  world. 


LACERATED  VOUNDS 

Let  us  study  a  case,  that  of  a  teamster,  forty  years  old,  soimd  and 
vigorous.  Twelve  hours  before  our  inspection,  while  unloading  his 
wagon,  he  let  fall  a  heavy  iron  bar,  the  end  of  which  struck  his  calf  and 
inflicted  a  ragged  triangular  wound.  Some  six  inches  of  skin  were 
torn  up,  the  muscles  lacerated,  and  the  head  of  the  fibida  exposed.  The 
bleeding  was  inconsiderable.  At  the  time,  he  wrapped  an  old  hand- 
kerchief about  the  leg,  passed  a  painful  night,  and  entered  the  hospital 
in  the  morning. 

Fort)-five  years  ago,  in  the  days  of  the  Civil  War,  such  an  injury 


LACERATED    WOUNDS  733 

might  eventually  have  led  to  amputation ;  even  now  it  is  not  without  its 
clangers.  Septic  material  has  undoubtedly  been  carried  deeply  into 
the  leg.  The  iron  bar  itself  was  unclean,  and  the  man's  well-worn, 
sweat-soaked  working  trousers  were  far  from  aseptic,  while  the  skin  of 
the  leg  itself  is  loaded  with  organisms. 

Two  courses  are  open  to  us  in  such  cases — to  clean  up  the  leg  and 
the  wound,  apply  wet  antiseptic  dressings,  and  look  for  a  slow  healing 
b}'  granulation,  or  to  bring  the  severed  skin  and  soft  parts  back  into  place 
and  try  to  obtain  a  prompt  healing  by  primary  union. 

"\A'e  adopted  the  latter  course,  and  through  the  application  of  our 
two  great  surgical  principles — asepsis  and  physiologic  rest — we  looked 
for  a  good  result.  That  pleasant  old  Frenchman,  Le  Dran,  in  1735, 
used  to  tell  his  classes  that  in  such  cases  as  this  he  always  tried  for  a 
primary  union,  because  if  that  failed  through  catching  cold  in  the  wound, 
he  could  take  out  his  stitches  and  expect  a  second  intention.  I  suppose 
that  phrase  "catching  cold"  is  as  old  as  Hippocrates. 

Of  course,  Le  Dran's  reasoning  still  holds  good,  though  to  us  now 
such  a  method  seems  a  half-hearted  way  to  approach  a  surgical  problem. 

In  the  case  of  the  teamster  we  begin  our  proceedings  by  etherizing 
the  patient.  It  is  cniel  as  well  as  stupid  to  attempt  a  painful  and 
extensive  dressing  without  an  anesthetic.  The  leg  is  shaved  and 
thoroughly  scrubbed,  then  the  wound  is  mopped  out  with  dioxid  of 
hydrogen,  followed  by  bichlorid  alcohol  1  :  3000.  Bits  of  torn  cloth- 
ing and  dirt  are  picked  out  first.  If  we  look  carefully,  we  see  that 
the  fragments  of  torn  muscle  are  viable;  they  bleed  easily  and  can  be 
reunited.  The  sewing  of  them  properly  is  important  for  two  reasons — 
because  if  left  loosely  flapping,  no  good  muscle  union  will  result  and 
the  leg  will  by  so  much  be  weakened,  and  because  the  drawing  of  them 
together  fills  up  the  cavity  between  and  prevents  the  collection  of  blood 
where  it  would  serve  as  a  culture-medium  in  that  ''  dead  space."  Let 
me  quote  Le  Dran,  who  said  that  in  a  deep  wound  in  which  the  muscles 
are  divided  obliquety  the  deep  stitches  should  be  passed  so  as  to  i-un 
parallel  with  the  muscle-fibers,  and  not  obliquely,  as  would  be  natural  in 
sewing  up  an  incised  wound. 

Having  closed  in  the  deep  parts,  we  lead  into  the  bottom  of  the 
wound  a  single  strip  of  absorbent  tape  or  wick,  placing  it  gently  and 
loosely,  that  it  may  act  as  a  drain  and  not  as  a  cork.  The  skin  is  now 
dra-v\Ti  over  the  restored  muscle,  and  stitched  into  place  with  a  half- 
dozen  silver  or  silkworm-gTit  stitches.  The  leg  is  again  washed  with 
bichlorid  alcohol  and  elevated  in  the  air,  thoroughly  to  drain  the  veins 
and  promote  freer  circulation.  Asepsis  is  complete;  then  comes  the 
second  step — support  and  immobilization. 

In  this  case  we  bind  the  muscles  from  the  toes  to  the  middle  of  the 
thigh; — first,  covering  the  wound  with  a  handful  of  loose  absorbent 
gauze,  to  act  as  a  drain  and  reservoir  for  the  inevitable  discharges,  then 
firmty  and  snugly  apph-ing  our  mill-board  and  wadding  rollers.  One 
sees  how  securely  they  hold  the  leg  and  how  the  knee  and  ankle  both 
are  immobilized  without  discomfort. 


734  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

We  cannot  put  the  leg  in  an  ordinary  sling  as  we  did  the  arm,  but 
we  can  keep  it  elevated,  and  so  add  greatly  to  the  jjatient's  (-(jnifort. 
Of  course,  this  man  lies  in  bed  for  a  few  tlays.  \\'e  swing  a  gauze  ham- 
mock from  a  rod  which  is  stretched  from  the  headboard  to  the  foot  of 
his  bed.  In  this  hammock  the  whole  leg  rests,  from  foot  to  hip.  That 
is  a  most  satisfactory,  comforting  device.  It  gives  us  our  required 
support  and  elevation,  and  as  it  swings,  it  allows  the  patient  to  shift 
himself  about  and  even  turn  in  bed  without  disturbing  the  wounded  leg; 
for  as  the  body  moves,  the  hammock  swings,  but  the  leg  remains  rela- 
tively at  rest. 

On  the  second  day  the  wick  is  removed  under  the  strictest  aseptic 
precautions;  the  leg  is  bound  up  again,  and  at  the  end  of  a  week  we 
show  it  soundly  healed. 

Ambroise  Pare  wrote  to  his  petit  maistre  in  1580:  '  M.  le  Prince  de  la 
Roche-sur-Yon,  who  clearly  loved  the  king  of  Navarre,  drew  me  aside 
and  asked  if  the  wound  were  mortal.  I  told  him  Yes,  because  all  woutids 
of  great  joints,  and  especially  contused  wounds,  were  mortal";  and  in 
the  sequel  the  King  of  Navarre  died. 

Ten  years  ago,  a  friend  of  mine,  while  leading  a  landing  party 
on  the  coast  of  Cuba,  was  shot  through  the  elbow  by  a  Mauser  rifle. 
The  wound  was  properly  dressed  and  supported,  and  in  the  course  of 
a  month  the  use  of  the  arm  was  restored  perfectly. 

A  patient  who  illustrates  our  subject — wounds  of  joints — is  an  Italian 
recently  in  a  street  row.  He  came  out  of  it  with  an  ugly,  ragged  cut, 
which  nearly  severed  the  insertion  of  the  triceps  tendon  and  laid  open 
freely  the  elbow- joint  from  behind.  As  we  hold  the  edges  of  the  wound 
apart,  we  see  the  articulating  surface  of  the  olecranon  and  a  bit  of  the 
internal  condyle.     Let  us  attempt  to  save  the  arm  with  a  useful  joint. 

The  man  is  etherized,  the  arm  carefully  disinfected,  and  while  an 
assistant  holds  the  wound  open,  we  wipe  out  the  joint  with  little  gauze 
sponges  dipped  in  bichlorid  alcohol,  and  then  douche  it  thoroughly  with 
sterilized  water,  taking  pains  all  the  time  not  to  bruise  or  othei'wise 
injure  the  serosa,  lest  we  set  up  an  adhesive  inflammation  which  might 
lead  to  ankylosis. 

Next,  with  fine  catgut  stitches,  we  sew  up  the  rent  in  the  capsule  and 
unite  accurately  the  severed  ends  of  the  triceps  muscle.  In  sewing 
up  the  capsule  take  special  pains  to  evert  the  edges,  that  no  rough 
surface  be  turned  into  the  joint  to  cause  mechanical  irritation.  Then 
the  skin-wound  is  brought  together,  and  covered  in  with  gauze  pads. 
In  the  final  binding  of  this  arm  we  have  to  meet  a  problem  which  differs 
from  most  of  those  encountered  in  the  upper  extremity.  We  cannot, 
flex  the  elbow  and  support  it  in  a  sling,  for  by  so  doing  we  should  run 
the  risk  of  tearing  the  freshly  se-^-n  triceps.  So  the  arm  is  put  up  in 
extreme  extension,  with  our  mill-board  strips  to  preserve  fixation,  and 
plenty  of  cotton  rollers  to  give  elasticity  and  comfortable,  even  com- 
pression. 

This  man  is  not  allowed  to  go  out  with  his  arm  swinging  at  his  side. 
The  wound  is  a  serious  one,  and  demands  great  care  for  a  few  days. 


LACERATED   WOUNDS  735 

He  is  put  to  bed  aiul  the  nrm  kept  at  an  angle  of  45  degrees,  either  on 
pillows  or,  as  1  prefer,  in  our  gauze  hammock. 

Not  long  ago  1  was  asked  by  a  physician  in  a  neighboring  town  to 
see  a  patient,  with  a  view  to  an  amputation.  The  man  was  suffering 
from  a  wound  somewhat  similar  to  this  last  one,  but  in  the  knee-joint. 

He  had  received  his  injury  ten  days  previously.  Not  realizing  its 
gravity,  he  had  neglected  to  call  a  physician,  contenting  himself  with 
lying  in  bed  and  keeping  the  knee  wet  with  applications  of  "  listerine." 
My  friend  had  seen  him  only  a  few  hours  before  my  visit.  I  found 
the  patient  to  be  a  middle-aged,  sturdy  sea-captain.  He  was  lying  in 
bed  and  was  evidently  in  pain.  There  was  a  punctured  wound  on 
the  outer  side  of  his  right  knee-joint.  The  edges  were  gray  and  sloughy 
looking,  and  a  thin  pus  could  be  pressed  out  through  the  opening.  A 
culture  from  this  discharge  showed  later  a  staphylococcus  infection. 
The  whole  knee  was  red,  boggy,  tender,  and  swollen,  the  dimples  on 
either  side  of  the  patella  being  obliterated,  and  the  synovial  pouch 
distended  three  fingers'  breadths  above  the  patella.  The  man's  tem- 
perature that  morning  was  100°  F.,  and  his  pulse  110;  his  face  was 
flushed,  appetite  nil,  and  the  picture  that  of  a  very  sick  man.  There 
was  present  a  leukocytosis  of  26,000. 

I  agreed  with  my  consultant  that  an  amputation  must  be  considered, 
but  advised  making  an  attempt  first  to  save  the  leg.  The  patient  was 
etherized,  the  leg  cleaned  up,  and  the  wound  enlarged  so  as  to  admit 
of  thorough  exploration  of  the  joint.  The  serosa  was  seen  to  be  deeply 
injected,  and  several  ounces  of  pus  were  evacuated,  but  the  integrity 
of  the  joint  apparently  was  not  yet  affected.  The  whole  interior  surface 
was  carefully  and  laboriously  mopped  with  dioxicl  of  hydrogen  and 
douched  with  sterilized  water.  Counteropenings  on  the  inner  side 
of  the  patella  and  in  the  popliteal  space  were  made  for  drainage  and 
tapes  were  inserted  in  all  the  wounds.  Then  a  large  absorbent  pad 
was  placed  about  the  knee,  the  leg  thoroughly  wrapped  and  supported 
after  our  familiar  fashion — the  dressing  extending  from  the  toes  to  the 
groin.  The  leg  was  slung  in  a  hammock,  \  grain  of  morphin  hypo- 
dermically  was  administered,  and  the  patient  was  left  with  careful 
directions  that  his  bowels  be  kept  open  by  salines  and  his  strength 
supported  by  frequent  liquid  nourishment  and  a  drink  of  Scotch  whisky 
three  times  a  day. 

Of  course,  in  this  case  we  did  not  look  for  the  restoration  of  a  sound, 
flexible  knee-joint.  The  best  outcome  to  be  expected  was  the  saving 
of  the  leg  with  a  stiff  knee.  I  did  not  hear  of  that  man  again  for  seven 
days,  when  my  friend  again  asked  me  to  see  him  and  to  do  the  dressing. 
The  picture  he  presented  was  most  refreshing.  Except  for  pallor  and 
feebleness,  all  evidence  of  sickness  had  left  the  patient  and  he  received 
me  with  the  comfortable  assurance  that  he  was  well.  During  the  week 
the  wicks  had  been  changed  three  times  by  his  attendant,  and  I  re- 
moved them  for  good  and  all.  On  taking  off  the  dressing  I  found  the 
leg  pale  and  the  skin  shriveled  in  appearance,  with  the  familiar  contour 
of  the  joint  restored.     There  was  slight  though  rather  painful  motion. 


736  MINOR    SURGERY— DISEASES    OF   STRUCTURE 

which  I  did  not  encourage.     The  two  wounds  were  granulating  well. 
Eventually  the  patient  recovered  with  joint  motion  of  20  degrees. 

This  was  a  gratifying  result.  I  attribute  it  to  the  man's  remarkably 
good  general  condition,  supplemented  by  the  strict  enforcement  of  our 
cardinal  rules — asepsis  and  support. 

Let  us  return  for  one  moment  to  that  other  man — the  tinsmith,  whose 
cut  hand  we  sewed  up. 

It  was  not  seen  for  ten  days,  though  he  reported  to  assure  us  of 
his  comfort  and  the  absence  of  pain.  Freed  of  its  dressings,  the  wound 
is  found  to  have  healed  per  primam,  as  was  to  be  expected.  We  confine 
the  hand  in  a  light  bandage  for  five  or  six  days  longer  and  then  send  the 
man  back  to  his  work. 

All  these  are  good  results  only,  but  one  must  not  conclude  from  them 
that  surgeons  are  wizards.  Bad  results — unavoidably  bad  results — 
come  often  enough,  and  we  see  a  plenty.  For  the  present,  we  are  illus- 
trating the  constant  saying  of  Ambroise  Pare,  ''  I  dressed  him,  and  God 
healed  him." 

COMPOUND    (OPEN)    FRACTURES 

In  connection  with  the  subject  of  lacerated  wounds  we  must  con- 
sider compound  fractures.  They  are  no  more  than  special  varieties  of 
lacerated  wounds. 

These  fractures  were  regarded  with  extreme  alarm  in  the  old  days, 
and  are  still  not  to  be  treated  cavalierly.  Chelius,  of  Heidelberg,  wrote 
in  1821  that  "  the  inflammation  is  always  \ery  great  and  requires  strict 
antiphlogistic  treatment,  blood-letting,  leeches,  cold  applications,  and 
opium,"  and  that  mortification  and  delirium  tremens  may  occur  especi- 
ally in  old  people.  "  If  sleep  do  not  take  place,  death  is  the  consequence. 
On  dissection  frequently  there  is  exudation  on  the  arachnoid,  pus  in  the 
joints  and  in  the  sheaths  of  the  tendons."  All  of  which,  of  course,  re- 
sults from  the  fact  that  we  have  to  deal  with  a  lacerated  and  easily 
infected  wound,  which  involves  a  structure  of  low  vitality. 

Our  effort,  therefore,  must  always  be  to  substitute  a  closed  fracture 
for  an  open  one,  and  then  to  treat  the  damaged  bone  on  the  ordinary 
principles.  Here  again  we  come  back  to  that  matter  of  rigid  asepsis 
and  immobilization,  the  latter  being  of  great  importance,  for  broken 
bones  which  are  not  held  strictly  at  rest  keep  up  an  irritation  of  the 
wounded  soft  parts,  delay  healing,  favor  the  continued  outpouring  of 
a  serohemorrhagic  exudate,  and  so  provide  a  medium  for  the  develop- 
ment of  micro-organisms. 

The  young  woman  whose  case  we  consider  first  was  jostled  against 
a  moving  cart,  and  her  arm,  thrust  between  the  spokes  of  the  wheel, 
was  severely  mangled.  On  being  brought  to  the  hospital  shortly  after- 
ward, it  was  found  that  both  bones  of  the  forearm  were  broken  in  the 
middle  third  and  that  the  two  upper  fragments  were  protniding  through 
a  hole  in  the  skin  on  the  dorsum.  The  house  surgeon  who  dressed  the 
case  very  properly  was  not  content  with  mere  reduction  of  the  fracture, 
but  with  pains  and  elaboration  restored  the  continuity  of  all  the  severed 


COMPOUND    (open)    FRACTURES  737 

parts.  The  wound  was  enlarged  by  free  incisions,  all  bleeding  com- 
pletely checked,  the  bone  fragments  placed  in  apposition,  the  wound 
thoroughly  douched  with  antiseptics,  torn  muscles  and  fascia  sutured, 
the  skin  wound  closed,  and  the  arm  carefully  dressed  and  secured  in 
wooden  splints. 

This  free  opening  and  cleaning  up  of  compound  fractures  is  especially 
important  when  the  forearm  is  involved,  for  in  it  non-union  frequently 
occurs,  owing  to  the  interposition  of  muscle  fragments  or  tendons 
between  the  ends  of  the  bones. 

In  the  present  case  the  arm  was  bound  firmly  to  the  side  to  insure 
perfect  rest.  After  recovering  from  ether  the  young  woman  experienced 
little  pain;  the  next  morning  her  temperature  was  99°  F.  It  never 
rose  higher,  and  we  presumed  fairly  that  the  superficial  wound  had 
healed  satisfactorily  after  six  days.  On  removing  the  dressings  we 
found  our  presumption  to  be  justified.  The  skin  wound  was  soundly 
healed ;  there  was  no  swelling  or  redness,  and  we  were  left  to  treat  the 
case  as  a  simple  fracture. 

Another  case  was  a  much  more  difficult  one,  illustrating  a  point 
which  I  have  made  before.  The  man,  a  brakeman,  was  forty  years  old. 
Four  months  previously  he  had  his  left  humerus  broken  by  being 
crushed  between  two  freight  cars.  The  fracture  was  a  compound  one, 
but  the  external  opening  healed  readily,  and  under  a  properly  applied 
plaster-of-Paris  dressing  union  of  the  bone  was  going  on  well,  as  we 
supposed.  After  a  month,  however,  non-union  was  apparent,  and  after 
two  months  the  condition  had  not  improved.  A  careful  investigation 
of  the  man's  past  history  then  revealed  the  fact  that  some  five  years 
before  this  he  had  a  venereal  sore,  fohowed  by  an  inguinal  adenitis 
and  a  skin  eruption,  for  which  he  submitted  to  about  six  months  only  of 
treatment.  He  was  now  put  on  mercurials  and  iodids  for  a  presuma- 
ble syphiHs,  with  the  result  that  after  another  month  fair  union  was 
established,  so  that  we  find  his  left  arm  as  sound  as  its  fellow.  That 
question  of  an  old  syphilitic  infection  is  never  to  be  lost  sight  of  in  these 
cases  of  delayed  union.  The  other  more  frequent  general  diseases 
which  may  complicate  recovery  are  tuberculosis,  diabetes,  malaria,  and 
that  indefinite  thing  which  we  call  rheumatism. 

Our  third  case  was  a  more  serious  affair  than  either  of  the  two  pre- 
ceding, but  is  interesting  because  it  shows  how  bad  may  be  the  results 
which  sometimes  follow  the  careful  conservative  surgery  even  of  to-day. 
The  subject  is  a  man  of  sixty  who  has  all  the  appearance  of  having 
led  a  laborious  life.  He  has  an  obvious  arteriosclerosis,  though  a 
thorough  examination  of  the  chest  and  kidneys  ehcits  nothing  abnormal. 
As  old  John  Abernethy  remarked  on  opening  his  surgical  lectures  a 
hundred  years  ago:  "  Now  I  say  that  local  disease,  injury,  or  irritation 
may  affect  the  whole  system;  conversely,  that  disturbance  of  the  whole 
system  may  affect  any  part."  That  ancient  fact  is  the  cmx  on  which 
this  case  turns. 

The  man  is  a  weaver.     About  six  weeks  before  I  saw  him  his  left 
hand  was  caught  in  his  machine  and  severely  torn  at  the  wrist.     The 

47 


738  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

radius  was  fnicturcd,  the  ulna  dislocated,  the  wrist-joint  opened,  the 
skin  and  other  soft  parts  over  the  dorsum  severely  nian<;led,  and  he 
was  brought  to  the  Massachusetts  Cieneral  Hospital  with  the  hand  hang- 
ing- off,  attached  only  by  the  skin  and  tendons  of  the  front  of  the  wrist. 
There  again  was  the  question  of  completing  the  amputation  which  the 
machine  had  begun,  or  of  attempting  to  save  the  hand.  I  determined 
on  the  latter  seemingly  hopeless  undertaking. 

After  the  usual  carefid  preparation,  two  loose  fragments  of  the 
radius  were  removed,  including  the  articulating  surface,  and  the  pro- 
truding end  of  the  ulna  was  cut  off,  in  order  to  convert  the  injury  from 
a  compound  fracture  and  dislocation  into  a  compound  fracture  which 
woidd  be  more  likely  to  heal  than  would  the  contused  and  lacerated 
joint.  As  a  result  of  this  removal  of  the  ends  of  the  forearm  bones, 
we  produced  a  partial  resection  of  the  joint,  which  would  mean  for  him 
at  best  a  hand  with  considerable  impairment  of  motion.  Then  the 
torn  tendons  were  secured,  trimmed  up,  and  united,  tape  drainage  was 
inserted,  the  skin  wound  sewn  with  silver  wire,  and  the  arm  put  up 
in  the  mill-board  apparatus.  The  patient  was  put  to  bed  and  the  limb 
slung  in  a  hammock. 

The  case  went  as  badly  as  it  could  well  have  done.  That  night 
the  patient's  temperature  was  100°  F.  and  his  pulse  100.  The  next 
morning  the  temperature  and  pulse  were  101°  and  90  respectively.  The 
dressing  was  taken  down,  the  skin  stitches  removed,  and  the  wound 
cleaned  up,  but  that  night  the  temperature  had  reached  103°  and  the 
pulse  120.  The  next  day,  two  days  from  the  accident,  the  patient's 
condition  was  alarming.  With  temperature  at  102°  and  pulse  112,  he 
had  every  appearance  of  being  thoroughly  septic,  as  it  is  called.  Evi- 
dently the  wound  was  an  active  streptococcus  factory,  pouring  pyo- 
genic organisms  and  their  products  into  the  general  circulation.  The 
patient's  arm  showed  a  striking  picture — such  a  picture,  fortunately,  as 
we  seldom  see  in  these  days.  The  wound  was  sloughy  looking,  and 
exuded  a  thin,  sanious  pus.  The  whole  forearm  and  hand  w^ere  swollen, 
tense,  red,  and  shiny.  The  skin  of  the  back  of  the  hand  was  blue  and 
necrotic  looking,  and  it  was  evident  that  we  had  to  deal  with  the  incep- 
tion of  an  acute  gangrene. 

Not  least  significant  was  the  patient's  general  appearance.  He  was 
hectic,  anxious,  and  restless,  with  that  almost  indefinable  septic  look, 
with  saffron  skin  and  injected  conjunctiva?,  which  experience  teaches 
us  to  associate  with  these  alarming  cases. 

Of  course,  there  was  but  one  thing  to  do.  The  rotting  arm  w^as 
killing  the  man,  and  it  must  be  taken  off.  I  amputated  it  about  3 
inches  above  the  limits  of  the  old  wound,  left  the  flaps  wide  open  for 
the  sake  of  more  complete  drainage,  and  had  the  satisfaction,  the  next 
day,  to  find  him  established  on  the  road  to  convalescence.  The  further 
story  is  uneventful. 

One  will  scarcely  find  a  case  to  illustrate  better  the  extreme  danger 
of  some  of  these  compound  fractures,  and  the  bearing  which  the  patient's 
state  of  general  health  may  have  on  the  local  lesion.     Here  the  man's 


COMPOUND  (open)  fkactuues  739 

premature  old  age,  and  the  general  impoverishment  of  his  system, 
consequent  upon  an  inefficient  circulation,  were  the  underlying  and 
salient  features.  He  could  put  up  no  fight  against  the  ovei-whelming 
bacterial  invasion,  and  so  capitulated  only  in  time  to  save  his  life." 

In  a  city  the  place  to  see  compound  fractures  is  at  a  general  hospital. 
— you  will  rarely  see  these  cases  in  private  practice.  Such  injuries 
occur  mostly  among  handicraftsmen,  day  laborers,  and  those  persons 
engaged  in  extra-hazardous  vocations,  such  as  railway  trainmen,  line- 
men, roofers,  firemen,  and  the  like;  and  these  men,  when  injured,  are 
commonly  taken  at  once  to  a  hospital.  So,  too,  with  any  person 
in  any  walk  of  life  who  may  be  injured  in  a  street  accident— he  is  im- 
mediately hurried  to  the  hospital  by  the  zealous  bystanders  or  police. 
It  is  fortunate  that  this  is  so,  for  in  a  hospital  is  found  the  fullest  equip- 
ment to  meet  these  emergencies,  and  a  competent  surgeon  is  always  on 
hand. 

The  commonest  and  perhaps  the  most  important  of  these  com- 
pound fractures  are  mangled  and  lacerated  hands.  We  see  them  daily. 
Let  us  study  a  man  suffering  from  such  an  injury.  I  say  that  these 
accidents  to  the  hand  are  most  important  because  serious  crippling  or 
loss  of  the  hand  means  a  loss  of  livelihood  to  the  victim,  and  to  the 
surgeon  each  of  these  cases  presents  a  fresh  problem  of  great  interest. 
Every  half -inch  of  finger  saved  and  every  joint  restored  is  of  importance. 
Most  of  all  the  thumb,  that  distinctive  mark  of  a  higher  evolution,  is  to 
be  preserved  if  possible.  The  thumb  without  the  fingers  may  still 
adorn  a  stump  capable  of  grasping  a  tool  and  doing  work,  but  a  hand 
deprived  of  the  thumb  is  a  futile  member. 

The  present  patient  is  a  machinist,  whose  right  hand  was  caught 
between  cog-wheels.  We  take  off  the  bloody  wrappings  and  find  all 
four  fingers  mangled,  but  the  thumb  uninjured.  A  flap  of  skin  over 
the  dorsum,  with  its  pedicle  toward  the  wrist,  was  torn  up,  disclosing 
the  second  and  third  metacarpal  bones,  which  were  fractured.  The 
whole  of  the  forefinger  was  mashed,  the  joints  opened,  and  the  distal 
phalanx  wanting.  There  was  no  prospect  of  saving  that  forefinger, 
but  the  other  fingers,  though  lacerated,  might  be  saved.  Such  a  hand 
means  a  study  in  reconstruction,  and  perhaps  two  hours  of  painstaking 
work  at  patching  and  mending.  Ether  and  asepsis  are  our  first  steps; 
all  bleeding  is  checked,  every  torn  tendon  is  stitched  and  replaced,  bits 
of  destroyed  tissue  are  trimmed  away,  hopelessly  comminuted  bone 
fragments  are  removed,  each  finger  is  treated  as  a  separate  problem 
and  given  its  appropriate  dressing,  skin-flaps  are  dravm  up  to  cover 
exposed  stumps,  and  the  forefinger  is  amputated  at  the  middle  of  the 
first  phalanx.  When  all  this  is  accompHshed  satisfactorily,  the  hand 
is  spread  out  upon  a  well-padded  splint,  with  dry  gauzes  about  and 
between  the  fingers,  and  the  limb  to  the  elbow  is  put  up  in  an  abundant 
elastic-compression  dressing.  It  is  important,  in  such  a  case,  as  in  the 
case  of  the  man  with  a  cut  palm,  that  the  muscles  of  the  forearm  and 
hand  be  immobilized  absolutely.  We  must  have  no  dragging  on  those 
freshly  united  tendons  and  delicate,  new-forming  tissues. 


740  MINOR   SURGERY — DISEASES  OF   STRUCTURE 

Then  the  arm  is  supported  carefully  in  a  sling  or  held  high  on  the 
chest  in  a  Velpeau  bandage.  If  all  goes  well,  the  patient  may  expect 
the  use  of  his  hand  by  the  end  of  two  months,  but  we  can  give  him  no 
such  positive  assurance.  Skin-flaps  may  lose  their  vitality;  bones 
may  suffer  from  osteomyelitis  and  become  necrotic;  tendons  may 
slough;  sinuses  leading  to  deep-seated  inflammations  may  persist  for 
weeks,  and  many  and  various  minor,  secondary  operations  may  be 
necessary  before  we  are  through  with  the  case.  But  the  great  pre- 
liminary care  is  worth  the  patient's  while  and  ours.  ^^'ith  such  care 
we  can  promise  him  a  useful  hand ;  without  it  he  would  have  to  expect 
a  crippled,  helpless  claw. 

In  connection  with  this  subject  of  lacerated  hands  I  must  warn 
the  reader  that  he  will  find  the  treatment  of  lacerated  feet  a  still  more 
difficult  matter.  It  is  not  because  there  is  anything  peculiar  in  the 
structure  of  the  feet,  but  because,  owing  to  their  dependent  position, 
their  circulation  is  not  so  good  as  is  that  of  the  hands,  except  in  the  case 
of  the  young  and  vigorous. 

Take  two  similar  cases — a  man  with  a  jammed  thumb  and  a  man 
with  a  jammed  toe.  One  may  dress  up  the  former  and  send  him  home, 
to  find,  in  the  course  of  a  couple  of  weeks,  that  he  is  quite  well.  One 
may  dress  the  man  with  the  jammed  toe  and  send  him  off  about  his 
business,  and  what  does  one  find?  By  the  end  of  two  weeks,  in  sj^ite 
of  careful  oversight,  the  toe  is  far  from  healed:  it  is  red,  tender,  and 
slightly  septic;  the  whole  foot  is  swollen  and  tender,  and  very  hkely 
there  is  a  bit  of  necrotic  phalanx  to  be  felt.  This  untoward  result  is 
due  to  no  lack  of  aseptic  precautions,  but  to  the  fact  that  we  have  failed 
to  observe  our  second  cardinal  principle — support.  One  cannot  safely 
send  these  patients  out  to  knock  about  the  streets.  Either  they  must 
be  put  to  bed  with  the  leg  elevated — the  best  thing  by  far — or  the}'  must 
be  instructed  to  bear  no  weight  on  the  foot  and  to  keep  it  up  on  a  chair 
or  sofa  except  when  necessarily  in  use.  The  point  sounds  like  a  small 
one,  but  it  is  salient. 

So  much  for  compound  fractures — perhaps  the  most  important 
division  of  traumatic  surgery.  We  have  but  skirted  the  border  of  a 
great  subject,  but  sufficiently  near,  I  tnist,  to  show  that  here,  as  in  the 
lesser  lesions  considered,  the  same  broad,  inevitable  principles  constantly 
must  be  applied. 

GRANULATING   WOUNDS   AND  VARICOSE  ULCERS 

There  exists  in  the  minds  of  students,  and  often  of  practitioners  as 
well,  a  confusion  regarding  ulcei's  and  granulating  woimds.  It  is  a 
natural'  confusion,  for  the  two  conditions  overlap  and  run  into  each 
other.  An  ulcer  may  be  described  as  a  superficial  solution  in  con- 
tinuity, which  shows  no  tendency  to  heal;  a  granulating  wound,  as  a 
solution  in  continuity,  which  shows  a  tendency  to  heal.  Of  course,  such 
a  definition  is  a  general  one,  but  it  will  answer  our  present  purposes. 

Ordinarily,  there  is  no  question  when  we  are  dealing  with  a  granu- 


GRANULATING    WOUNDS   AND    VARICOSE    ULCERS  741 

luting  wound.  We  see  the  red,  velvety  granulations  shrinking  in  area 
steadily,  with  little  projections  of  new  skin  shooting  in,  and  the  process 
of  repair  so  constant  and  inevitable  that  one  may  appreciate  the  changes 
from  day  to  day. 

In  regard  to  such  a  healthy  granulating  wound  there  are  two  ques- 
tions which  the  student  is  always  asking,  and  about  which  he  seems  to 
feel  that  he  gets  very  httle  light.  With  what  applications  shall  it  be 
treated,  and  how  often  shall  the  dressing  be  changed? 

Ordinarily,  the  answer  to  that  first  question  is  a  very  simple  one 
when  the  wound  is  in  a  healthy  individual.  I  have  shown,  for  instance, 
a  woman,  whose  breast  was  removed  for  sarcoma  some  three  weeks 
before.  The  skin-flaps  were  not  drawn  tightly  together  at  one  point, 
with  the  result  that  she  had  on  the  front  of  the  chest  a  superficial  open 
wound  about  the  size  of  a  silver  dollar.  It  was  clean,  flat,  bright 
crimson,  and  did  not  bleed  easily.  It  will  heal  over  in  a  few  days, 
no  matter  how  treated,  provided  only  and  this  is  important — provided 
it  be  kept  clean.  One  can  wash  it  with  corrosive  alcohol  or  creolin, 
put  on  a  gauze  cocoon,  and  leave  it  for  three  or  four  days.  The  raw 
area  shrinks  from  day  to  day.  Such  wounds  as  this  require  no  special 
care. 

On  the  other  hand,  take  the  case  of  a  granulating  wound  on  the 
back  of  the  neck  in  a  patient  fifty  years  old  who  has  2  per  cent,  of  sugar 
in  his  urine,  for  which  he  is  under  treatment.  Two  weeks  previously  he 
showed  on  the  back  of  his  neck  a  carbuncle  the  size  of  an  English  walnut. 
We  excised  cleanly  the  carbuncle,  and  so  stopped  the  process.  There 
was  no  return  of  the  active  local  infection,  but  the  wound  did  not 
heal.  The  raw  surface,  as  large  as  the  top  of  an  egg-cup,  remained 
without  healing,  the  granulations  dark  purple,  soft,  spongy,  bleeding 
easily  when  handled,  and  overlapping  in  fringes  about  the  edges.  That 
overlapping  we  caU  exuberant  granulations;  it  is  a  perfectly  harmless 
condition,  and  is  easily  remedied.  It  is  the  condition  known  to  the 
laity  as  "proud  flesh,"  and  is  always  referred  to  with  horror  by  them 
— just  why  is  not  clear. 

There  are  various  methods  of  treating  such  granulations,  but  all 
methods  come  down  to  this,  that  the  granulations  must  be  trimmed 
down  and  the  wound  stimulated  into  proper  activity,  so  that  it  shall 
have  the  vigorous  healthy  appearance  which  we  saw  in  the  case  of  the 
woman.  With  the  scissors  cut  off  these  redundancies, — they  are  abso- 
lutely insensitive, — and  after  checking  the  oozing  by  sponge  pressure, 
wipe  over  the  whole  wound  with  the  stick  of  silver  nitrate.  Then 
apply  a  dry  gauze  dressing.  Every  other  day  the  man  returns,  and 
we  soon  see  the  wound  closing  in.  Another  excellent  method  of  treat- 
ing such  a  wound,  after  trimming  the  granulations,  is  to  dust  it  thickly 
with  some  simple  drying  powder,  such  as  dermatol  or  aristol.  But  after 
all,  what  one  must  bear  in  mind  is  that  the  wound  is  to  be  kept  clean 
and  the  granulations  frequently  trimmed  down.  Our  familiar  support- 
ing bandage  must  never  be  omitted,  for  the  pressure  it  exercises  helps 
the  circulation  in  the  parts. 


742 


MINOR    SURGEUY — DISEASES    OF    STRICTURE 


A  third  type  of  firanuluting  avouiuI  is  seen  in  a  boy  who  received  a 
severe  kick  on  the  shin  about  a  month  before  I  showed  him  to  my  chiss. 
The  periosteum  and  bone  were  not  injured,  but  he  slunved  a  superficial 
wound,  long  and  narrow,  as  though  one  had  torn  up  the  skin  for  a 
distance  of  5  inches  with  the  finger-nail.  One  week  later  this  long, 
narrow  wound,  in  the  apparently  healthy  lad,  began  to  be  lined  with 
small,  fiat,  dull,  red  granulations,  and  thus  it  had  remained.  It  refused 
to  heal.  It  had  been  scarified,' cureted,  and  wiped  frequently  with 
the  caustic,  but  without  avail.  We  had  the  lad  get  out  into  the  country 
to  see  what  out-of-doors  life  would  do  for  him.  Meantime  I  dressed 
the  wound  daily  with  a  stimulating  lotion  on  gauze  and  bandaged  the 
leg  from  toes  to  mid-thigh. 

In  such  cases  we  find  diluted  tincture  of  myrrh,  1  part  in  20  of  water, 
or  pure  balsam  of  copaiba,  to  be  excellent.     I  have  always  been  pleased, 

r- 


'■'^;»i-'*^: 


Fig.  460. — Incircling  ulcer  of  the  leg  (Massachusetts  General  Hospital). 

too,  with  the  action  of  Gamgee's  favorite  application:  Borax,  1  part; 
compoimd  tincture  of  lavendar,  8  parts;  glycerin,  4  parts;  water,  24 
parts. 

Such,  briefly,  are  some  of  the  methods  of  treating  these  open  wounds. 
We  find  in  the  t)ooks  and  are  told  by  physicians  of  innumerable  other 
lotions,  ointments,  and  applications.  Many  of  them  doubtless  are 
useful — certainly  most  of  them  are  harmless;  but,  after  all,  what  we  must 
remember  is  to  keep  the  wound  clean  and  to  give  nature  a  chance. 

Now  let  us  regard  another  class  of  cases — varicose  ulcers,  allied  to 
granulating  wounds,  cases  which  are  a  weariness  often  to  students  and 
dressers,  for  long-standing  ulcers  become  an  opprolirium  to  the  clinic. 
Yet  they  should  not  be  so.  These  ulcers  are  grievous  afflictions  to  their 
victims;  they  belong  to  an  interesting  class  of  pathologic  processes, 
and  they  heal  under  proper  treatment. 

For  hundreds  of  years  surgeons  have  talked   and  written   about 


GRANULATING   WOUNDS   AND    VARICOSE    ULCERS  743. 

varicose  ulcers,  and  the  opinions  of  the  best  surgeons  regarding  their 
nature  and  treatment  have  always  been  correct,  yet  even  to-day  one 
sometimes  sees  the  cases  drag  on  an  interminable  course,  submitted  to 
a  treatment  which  is  amazing  and  discouraging. 

One  may  usually  tell  a  varicose  ulcer  at  a  glance.  It  is  on  the  shm, 
below  the  middle  of  the  leg;  above  and  about  it  are  enlarged  superficial 
veins,  and  commonly  the  leg  is  swollen  more  or  less.  In  few  lesions  is 
the  cause  of  the  trouble  as  obvious  as  in  the  case  of  these  ulcers.  Ivnow- 
ing  the  cause,  one  must  remedy  that,  and  in  so  doing  attack  the  disease 
at^its  source.  These  ulcers  are  due  to  varicose  veins,  so  we  must  cure 
the  varicose  veins,  or  at  least  we  must  support  and  relieve  them. 

This  is  such  a  transparent  truism  that  it  seems  as  though  it  should 
be  apparent  to  the  meanest  intellect,  yet  wise  men  are  seen  to  pass  it  by. 
Think  for  a  moment  of  what  the  complex  process  is.  First,  there 
arises  the  dilatation  of  the  veins,  a  condition  lasting  perhaps  for  years; 
gradually,  as  the  walls  of  the  veins  become  thinned  and  inelastic  and 
their  valves  incompetent,  a  condition  of  venous  stasis  results.  A  thm 
serum  oozes  out  into  the  surrounding  tissues  and  causes  the  edematous 
swelling.  At  the  same  time  there  is  an  exudation  of  red  blood-corpus- 
cles, which  produce  an  extensive  pigmentation  of  the  skin,  associated 
not  infrequently  with  an  eczema.  As  a  result  of  all  this  the  nutrition 
of  the  leg  is  greatly  impaired,  and  the  ideal  conditions  favoring  an 
infection  with  destruction  of  tissue  are  present.  Sometimes,  as  a 
result  of  thrombosis  of  the  veins  and  malnutrition  of  the  surrounding 
parts,  a  phlebitis  or  a  periphlebitis  is  seen;  there  may  be  mpture  of  a 
vein  even  with  serious  hemorrhage;  but  more  commonly,  as  a  result  of 
some  sHght  blow,  or  even  scratch,  a  superficial  skin  lesion  is  caused. 
This  refuses  to  heal  in  the  sodden  tissues,'  bacteria  rush  m,  and  a  de- 
structive ulcer  is  formed.  ■ 

It  is  for  this  ulcer  that  the  victim  seeks  advice  at  last.  He  seeks 
advice  and  I  regret  to  say  he  sometimes  is  given  plasters  and  washes, 
—ostensibly  for  the  eczema,  I  suppose.  With  our  knowledge  of  the 
cause  of  his  trouble  we  say  that  such  treatment  is  preposterous.  _ 

Now  let  us  consider  one  of  these  unfortunate  patients.  He  is  a 
man  of  forty-five;  a  day  laborer;  a  man  who  stands  constantly  on  his 
legs  The  pain  of  his  disease  has  disabled  him  utterly.  One  observes, 
in  the  first  place,  the  great  size  of  his  calves  and  feet.  He  is  not  a  large 
man;  he  weighs  perhaps  165  pounds,  but  his  right  leg.  which  is  the 
seat  of  the  ulcer,  measures  20  inches.  The  whole  leg  below  the  knee 
is  of  a  dark,  reddish-browTi  color,  mottled  and  shmy.  There  the  veins 
are  disguised,  but  behind  the  knee,  in  the  popliteal  space,  and  along  the 
course  of  the  internal  saphenous  you  see  the  veins  standing  out  in  great 
bunches.  Over  the  front  of  the  shin,  and  spreading  back  into  the  calf, 
is  an  irregular  ugly  ulcer,  as  large  as  one's  outspread  hand  1*^  edges 
are  indurated  and  elevated,  and  it  is  lined  with  sloughy,  dull  red,  tiabby 
granulations.     As  the  man  says  truly,  it  is  a  very  sore  leg. 

The  patient  has  been  lying  on  the  examining  table  for  half  an  hour, 
with  his  leg  supported  at  an  angle  of  45  degrees.    That  has  demonstrated 


744  MINOR  SURGEKY — DISEASES   OF   STRUCTURE 

two  things:  It  has  given  us  an  idea  of  the  extent  of  the  sweUing,  for 
now  we  find  the  calf  to  measure  but  16A  inches  in  circumference, — a 
shrinkage  of  'Sh  inches, — and  it  has  given  us  an  important  clue  as  to 
treatment.  Indeed,  it  has  brought  us  back  to  our  first  principles,  and 
shown  us  the  importance  of  elevation  and  support.  For  let  me  assert 
that  the  method  ])y  which  most  cjuickly  we  should  secure  a  healing 
would  be  to  put  the  man  to  bed,  to  bandage  properly  the  leg  and  swing 
it  in  a  hammock.  Thus  the  veins  would  be  kept  constantly  emptied 
by  the  action  of  gravity;  the  circulation  would  be  quickened  and  the 
nutrition  reestal)lished ;  the  exudate  would  be  absorbed  in  a  few  days, 
and  the  ulcer  would  be  converted  into  a  granulating  wound. 

For  various  reasons  such  an  admirable  method  of  treatment  may 
not  be  instituted  in  the  case  we  are  considering,  so  we  must  adopt  the 
next  best  method,  and,  on  the  whole,  it  is  the  one  most  practicable  in 
such  cases. 

In  the  first  place,  when  there  is  any  considerable  edema  present, 
always  order  the  half-hour  of  elevation.  At  the  end  of  that  time  we 
find  that  we  have  to  deal  with  a  leg  of  a  more  nearly  normal  size,  with 
edema  diminished,  and  veins  emptied  of  their  accumulations.  Next, 
to  clean  up  the  sloughy  ulcer  with  its  indurated  border,  let  us  apply 
a  gauze  pad  wmng  out  of  pure  glycerin,  overlapping  the  edges.  The 
glycerin  acts  to  draw  out  the  serum  from  the  tissues  and  rapidly  softens 
the  indurations.  If  we  choose,  we  may  etherize  the  patient  and  curet 
the  ulcer  and  its  edges,  but  this  rarely  is  necessary.  Then  from  toes 
to  mid-thigh  apply  firmly,  snugly,  and  with  uniform  elastic  compres- 
sion our  wadding  rollers  of  many  thicknesses  and  a  cotton  bandage. 

Now,  whatever  position  the  patient  assumes,  the  veins  cannot  again 
become  distended,  the  leg  cannot  swell,  and  the  nutrition  of  the  parts 
cannot  seriously  be  disturbed.  The  patient  is  directed  to  keep  as  quiet 
as  possible  for  three  or  four  days  and  to  have  his  leg  up  on  a  chair  most 
of  the  time,  but  within  the  week  he  will  go  back  to  work  in  some  degree 
of  comfort.  After  the  first  day  he  will  return  to  have  the  glycerin  pad 
removed  and  the  bandages  reapplied. 

Consider  next  a  second  man,  who  is  suffering  from  a  similar  ulcer 
and  has  been  under  treatment  for  three  days.  He  was  dressed 
with  our  glycerin  pad  and  supporting  bandage,  which  has  been 
once  renewed.  We  find  now  a  condition  very  different  from  that  of 
our  control  patient.  The  leg  is  still  swollen  and  edematous,  but  not 
markedly  so.  The  veins  are  inconspicuous,  and  the  ulcer  itself,  instead 
of  being  indolent  and  sloughy  looking,  is  lined  with  red  and  fairly 
healthy  granulations;  in  other  words,  it  is  taking  on  the  characteristics 
of  a  granulating  wound.  As  for  further  treatment,  the  important  thing 
is  to  continue  our  support,  without  which  the  lesion  would  quickly 
relapse  into  an  ugly  ulcer.  To  the  granulations  apply  sterilized  al)sorb- 
ent  gauze.  Nothing  else  is  needed,  and  by  continuing  in  this  course 
for  three  weeks,  we  should  find  the  wound  nearly  healed  and  the  man 
going  about  in  normal,  comfortable  fashion. 


fklon;  whitlow;  i-akonychia;  palmar  abscess  745 

FELON;   WHITLOW;   PARONYCHIA;  PALMAR  ABSCESS 

We  tfluiU  iiiul  it  luuxl  to  define  the  first  three  wurds,  which  give  a 
title  to  this  piiragrapli.  Felon  and  whitlow  have  no  proper  etymologic 
reason  for  existence;  paronijckia  is  derived  obviously  from  Uapd,  around, 
and  ovo^,  nail;   palmar  abscess  is  self-evident. 

I  make  this  seemingly  needless  discourse  about  definitions  because 
no  two  surgeons  will  be  found  to  agree  about  the  meaning  of  those 
first  three  words,  and  the  medical  dictionaries  even  are  at  loggerheads. 

Felon  means  one  guilty  of  felony,  a  uickecl  cruel  person,  hence  the 
word  has  been  applied  to  a  cruel  infection.  Whitlow  means  literally 
a  white  flame;  "a  painful  inflammation  tending  to  suppurate,  in  the 
fingers  or  toes."  ^  That  seems  a  fairly  good  definition.  Many  surgeons 
regiird  whitlow  as  identical  with,  felon;  I  do  so  myself,  and  as  I  find  no 
great  authority  or  even  well-established  custom  to  oppose  me,  I  shall 
continue  to  do  so.  For  us  whitlow  and  felon  are  interchangeable 
terms. 

But  paronychia— there  is  our  rock  of  offense,  for  fully  half  the 
authorities  make  it  identical  with  whitlow  and  felon.-  So  we  are 
left  to  follow  our  own  fancies,  and  I  have  taken  the  liberty  of  following 
mine  so  far  as  to  contrive  two  definitions  which  I  beHeve  to  be  descrip- 
tive, convenient,  and  fairly  accurate: 

As  whitlow  is  felon,  and  the  latter  word  is  in  more  common  use, 
I  shall  drop  the  term  "whitlow." 

A  felon  is  an  acute  infection  of  the  finger  (or  toe),  progressive,  with 
a  tendency  to  involve  the  bone. 

A  paronychia  is  an  acute  infection  of  the  finger  (or  toe),  progressive, 
situated  near  the  nail,  which  it  tends  to  involve. 

Bear  in  mind  that  paronychia  may  spread  further  and  involve  the 
whole  finger— in  which  case  it  should  more  properly  be  caUed  a  felon. 
And  bear  in  mind  also  that  the  great  majority  of  felons  are  situated 
over  the  terminal  phalanx. 

This  is  a  beginning  only  of  the  controversy.  We  could  go  on  tor 
an  hour  juggling  terms  and  disputing  as  to  w^hat  does  or  what  does  not 

constitute  felon.  .      .   .      ■ 

Felon.— Conceive,  then,  of  felon  as  an  acute,  progressive  infection, 
situated  anywhere  on  the  finger.  It  may  be  superficial,  it  may  be  deep, 
it  may  be  both  superficial  and  deep.  Take  that  last  conception  as  an 
example  of  a  common  form  of  felon  and  examine  a  special  case. 

One   week   ago  a  patient   pricked  her  finger   with  a  carpet-tack. 
The  little  wound  healed  apparently,  but  after  three  days  the  end  of 
the  finger  became  red,  and  the  skin  over  the  pulp  become  elevated 
somewhat  in  the  form  of  an  ordinary  blister.     But  there  was  pam,  and 

1  Chambers'  Etymofogical  Dictionary.  , 

2  Foster,  Dunglison,   Keating,  Gould,  and  Duane  group  felon,   whtlo^\,   and 
paronychia  under  one  head,  and  caU  the  hybrid  affection  ' 'penplif^ngeal  abscess 
The  Century  Dictionary:  "  Felon,  an  acute  and  painful  inflammation  of  ttie  deeper 
tissues  of  the  finger  and  toe,  especiaUy  of  the  distal  phalanx;   generally  seated  near 
the  nail." 


746  MINUR   SURGERY — DISEASES   OF   STRUCTURE 

there  is  pain  now — throbbing,  wearing  pain.  We  tie  a  rul)ber  tourni- 
quet about  the  base  of  the  finger  and  inject  a  few  (hxjps  of  2  per  cent, 
cocain  along  the  course  of  each  lateral  nerve.  Then,  with  the  scissors, 
we  trim  off  the  blister.  That  leaves  a  sore  with  a  red,  mottled  surface 
about  the  size  of  a  silver  dime.  It  looks  like  a  granulating  area.  All 
the  seropus  contained  in  the  blister  has  been  evacuated,  and  one 
would  suppose  that  here  was  an  end  of  the  affair.  If  now  I  take  the 
finger  in  my  hand  and  gently  squeeze  it,  you  see  a  minute  drop  of 
pus  exude  slowly  from  a  point  in  the  granulations.  That  means  that 
there  is  a  little  track  connecting  the  superficial  cavity  we  have  opened 
with  a  deeper  cavity.  This  felon  is  a  compound  affair,  with  two  pus 
chambers  in  tiers,  one  above  the  other.  They  are  connected  by  the 
minute  channel  which  was  perhaps  the  original  track  of  the  carpet- 
tack,  or  perhaps  was  caused  by  the  inflammatory  action  itself. 

Treatment. — This  form  of  felon  with  its  two  chambers  has  been 
felicitously  termed  a  "shirt-stud  abscess."  There  may  be  two  or  more 
connecting  channels,  but  the  name  is  just  as  good.  So,  when  we  open 
a  superficial  felon,  let  us  remember  that  a  felon  is  progressive,  and 
search  for  that  second  chamber.  Now  we  open  the  deeper  pocket,  and 
find  ourselves  on  the  periosteum.  We  clean  out  the  little  cavity;  wipe  it 
thoroughly  with  dioxid  of  hydrogen,  lay  in  it  gently  a  bit  of  absorbent 
tape,  wrap  the  finger  in  a  hot  creolin  poultice,  bandage  the  hand  and 
forearm  with  elastic  compression,  and  suspend  them  in  a  sling. 

Let  me  say  one  word  about  poultices}  They  have  been  used  from 
time  immemorial  for  the  comfort  they  bring  to  the  affected  part.  Their 
action  is  to  stimulate  the  superficial  circulation,  and  thus,  by  relieving 
congestion,  to  check  inflammatory  action  and  allay  pain.  Such  a  use 
of  poultices  is  as  comforting  to-day  as  ever  it  was. 

A  poultice  must  supply  heat  and  moisture;  deprived  of  either,  it  is  no 
longer  a  poultice.  The  materials  of  which  poultices  have  been  made 
are  many,  but  mostly  surgeons  try  to  employ  some  vehicle  which  shall 
retain  heat.  Such  vehicles  are  found  in  Indian  meal,  flaxseed,  and 
the  various  cereals.  They  remain  moist  and  warm  for  a  long  time, 
but  they  are  beautiful  culture-media.  For  a  vigorous  infection-spread- 
ing agent,  recommend  me  to  the  old-fashioned  bread-and-milk  poultice. 

With  Listerism  there  came  in  the  so-called  antiseptic  poultice.  As 
commonly  used  it  is  not  antiseptic.  The  best  that  can  be  said  of  it 
in  that  regard  is  that  it  is  often  aseptic.  When  properly  prepared,  it 
is  a  useful  dressing,  because  it  is  sterile  and  because,  by  supplying  heat 
and  moisture,  it  stimulates  the  reparative  processes.  Then,  too,  it  is 
easily  applied. 

So  one  sees  that  in  the  use  of  the  properly  constructed  and  applied 
poultice  w^e  return  again  to  our  fiist  principles — we  support  the  part 
and  we  stimulate  and  equalize  the  circulation. 

That  form  of  antiseptic  poultice  which  I  prefer  is  made  of  sheet- 
wadding  pads  wa-apped  in  absorbent  gauze  and  covered  with  some 
waterproof  material,  like  oiled-silk  or  parchment  paper.  The  pads 
*  Compare  the  action  of  poultices  with  the  Bier  treatment. 


felon;  whitlow;  paronychlv;  palmar  abscess 


747 


are  wrung  out  of  a  hot  creolin  solution,  1 :  200.  One  may  use  bichlorid 
or  boric  acid,  but  carbolic  acid  never.  The  poultices  should  do  much 
more  than  cover  the  affected  region  only.  If  the  whole  finger  is  in- 
volved, wrap  the  hand;  if  the  hand  is  involved,  include  the  forearm  in 
the  poultice.  Thus  we  shall  quiet  the  adjacent  muscles  and  protect  the 
efferent  lymphatics.  It  is  well  also  to  put  on  a  light  splint  outside  of 
the  poultice  for  more  perfect  immobilization  of  the  parts. 

Then  as  to  the  drainage  of  these  abscesses — gauze  wicking  is  usually 
sufficient.     Do  not  jpack  the  cut  with  gauze.     That  will  cork  up  the 

r:         '  J.  •    ^ 


Fig.  461. — Examining  infected  axilla. 


pus.  Gauze  'packing  is  never  used  except  to  check  hemorrhage.  To 
drain,  lay  gently  into  the  cut  one  or  two  wicks  or  tapes.  These  will 
carry  off  by  capillarity  the  secretions,  and,  being  interposed  between  the 
cut  edges,  will  prevent  a  superficial  gluing  together  of  the  skin  wound 
and  a  consequent  pocketing  and  burrowing  of  pus  in  the  deeper  parts. 
To  demonstrate  further  the  treatment  of  felons  let  us  consider 
a  second  case.  The  patient  has  been  aware  of  a  throbbing  pain,  in- 
creasing in  severity,  for  four  days,  over  the  middle  phalanx  of  his 
ring-finger.  The  primaiy  cause  of  the  trouble  is  unknoTVTi  to  him. 
We  observe  that  the  whole  finger  is  hot  and  swollen,  and  on  compressing 


748  MIXOR   SURGERY — DISEASES   OF   STRUCTURE 

between  one's  thumb  and  fin^or  the  lateral  vessels  on  either  side  of 
his  finger  one  plainly  fools  thoni  throbbing.  That  is  a  distinctive  and 
interesting  point  in  the  tliagnosis  of  localized  inflammations  of  this 
type.  You  will  not  discover  that  pulse  in  cases  of  sprains  or  rheu- 
matoid affections.  The  man's  finger  is  not  only  swollen  throughout, 
but  its  palmar  skin  is  reddened,  elevated,  and  excessively  tender.  In 
feeling  carefully  in  his  axilla,  one  detects  an  enlarged  and  painful 
node.  His  body  temperature  is  not  elevated,  his  pulse  is  not  rapid, 
nor  is  there  a  noteworthy  leukocytosis — the  white  count  being  9000; 
but  he  is  tired  from  loss  of  sleep  and  weary  with  the  constant  pain. 
On  carrying  the  knife  deeply  down  through  the  skin  and  laying  bare 
the  tendon-sheath,  we  give  vent  at  first  to  an  abundant  bloody  oozing, 
which  is  good.  Then  there  follow  half  a  dozen  drops  of  pus,  in  which 
one  will  probably  find  streptococci  in  pure  culture.  If,  now,  content 
with  this  cut,  we  apply  the  dressing,  to-morrow  may  show  us  the  super- 
ficial parts  mostly  glued  together.  That  is  a  condition  we  do  not  want, 
for  the  wound  must  be  made  to  heal  by  granulation  from  the  bottom. 
To  favor  such  healing,  trim  off  the  skin-edges  so  that  they  cannot 
readily  be  brought  together — a  simple  and  veiy  useful  maneuver. 
Now  we  apply  the  poultice,  light  splint,  bandage,  and  sling. 

Properly  the  poultice  should  be  changed  twice  a  day  at  least,  and 
by  the  fourth  day  we  should  begin  to  see  a  clean,  granulating  wound. 
The  man  may  have  pain,  and  may  need  a  small  dose  of  morphin.  A 
certain  amount  of  pain  nearly  always  follows  a  cocain  operation  on  a 
felon,  but  by  the  next  day  the  patient  should  be  in  comfort. 

These  two  cases  have  been  simple  ones,  but  all  felons  are  by  no 
means  so  easy  of  treatment.  The  pus  burrows;  tendons,  bones,  and 
joints  are  involved;  slashing  incisions  and  amputations  may  be  neces- 
sary, and  at  the  best  some  impairment  of  function  is  apt  to  ensue. 
Such  results  you  shall  see  daily  in  my  clinic.  The  therapeutic  measures 
to  be  applied  differ  in  degree  only  from  those  you  have  seen. 
Pus  is  to  be  sought  out,  drainage  is  to  be  maintained,  asepsis  and  sup- 
port are  vigorously  to  be  enforced,  pain  is  to  be  relieved,  and,  always, 
the  general  condition  of  the  patient  is  to  be  considered  and  strengthened 
so  far  as  well  may  be.^ 

Let  us  study  a  third  patient,  who  presents  us  with  an  example  of 
paronychia.  In  the  limited  sense  in  which  w^e  use  the  term,  "parony- 
chia'' is  the  common  nursery  "run-round."  This  child  pulled  a  hang- 
nail a  few  days  ago  until  she  drew  blood,  and  so  infection  entered  in. 
Two  days  before  she  came  to  us  the  skin  about  the  base  of  her  nail  was 
reddened  and  painful,  forming  a  crescentic  swelling.  On  our  first 
inspection  there  is  pus  obviously  present,  for  it  shows  creamy  through 
the  thin  pellicle. 

There  is  a  common  way — a  common  but  wrong  way — of  opening  these 
little  abscesses.  That  wrong  way  is  to  cocainize  the  finger  and  draw 
the  knife  in  a  semicircle  through  the  skin  about  the  base  of  the  nail. 

^  The  opsonins  and  Bier's  treatment  are  giving  us  constantly  better  results  in 
the  treatment  of  these  serious  infections. 


felon;  whitlow;  paronychia;  palmar  abscess  749 

So  one  will  evacuate  the  pus,  but  will  have  left  an  ugly  sore  to  granulate 
slowly  up  with  the  underlying  nail  at  its  bottom. 

Here  is  a  better  way.  Lay  a  narrow-bladcd  knife  flat  upon  the 
nail  with  the  knifc-ixMiit  against  the  inflamed  skin,  and  by  a  little 
gentle  prying,  which  should  be  painless,  insert  it  along  the  skin-edge  and 
the  base  of  the  abscess.  Withdraw  the  point,  when  we  see  it  followed 
by  a  jet  of  pus.  By  a  little  manipulation  the  cavity  is  now  evacuated; 
a  poultice  is  then  applied.  Unless  the  nail  and  matrix  have  become  in- 
volved in  the  infection,  sound  healing  should  now  be  a  matter  of  two 
or  three  days  only. 

As  in  the  discussion  of  felons,  so  here,  we  have  scarcely  more  than 
touched  upon  a  broad  subject.  This  infection  may  rapidly  invade  the 
finger.  It  may  attack  and  destroy  nail  and  matrix,  and  involve  peri- 
osteum, bone,  joint,  and  tendon.     There  is  no  limit  to  its  possible 


tij£i^ 


Fig.  462. — Opening  paronychia  along  nail. 

ravages,  but  for  the  avoidance  of  confusion,  when  the  infection  has 
passed  beyond  the  region  of  the  nail,  we  speak  of  it  as  felon  and  not  as 
paronychia. 

Palmar  abscess  is  a  further  development  of  these  hand  infections. 
To  it  felon  and  paronychia  naturally  and  inevitably  lead.  It  is  a  lesion 
of  great  interest — in  its  pathology,  its  treatment,  and  its  capacity 
for  far-reaching  damage.  In  it  the  infection  usually  starts  in  the  palm, 
but  it  may  begin  in  one  of  the  fingers  and  spread  to  the  palm. 

The  methods  of  infection  are  therefore  various,  but  perhaps  the 
commonest  method  is  that  seen  in  the  hand  of  the  laboring  man. 
Take  the  case  of  a  gardener,  for  example.  His  hand  bears  heavy  cal- 
losities, which  have  become  so  hard  as  to  press  upon  and  irritate  the 
underlying  soft  structures.  This  bruising  has  caused  a  considerable 
blister,  which  has  become  infected  from  the  overlying  skin,  and  in  turn 
has  passed  on  its  irritating  properties  to  the  deeper  parts. 


750  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

As  one  looks  at  the  huiul,  it  appears  everywhere  swollen — back  as 
well  as  front.  That  puffy,  reddened  dorsum  is  swollen  from  edema.  If 
one  were  to  cut  into  it,  one  would  draw  serum  and  blood  only.  But  the 
palm  shows  a  condition  quite  different.  It  is  not  so  greatly  distended 
in  appearance  as  is  the  tlorsum,  for  its  deep  structures,  bound  down  by 
the  dense  palmar  fascia,  cannot  greatly  swell.  The  pain  is  there,  how- 
ever; and  it  is  all  the  more  severe  because  the  fascia  does  so  limit  the 
swelling.  In  order  to  escape  without  our  aid  the  pus  must  burrow  up 
under  the  annular  ligament,  into  the  forearm,  and  that  is  what  we  fear. 
So  you  see  the  palm  of  the  hand  to  be  tense  and  brawny,  but  not  greatly 
swollen.  It  is  exquisitely  sensitive  to  pressure.  The  pus  must  be  let 
out  quickly,  and  here  again  we  are  presented  with  a  problem  which 
is  rendered  interesting  by  reason  of  anatomic  complications.  Few 
other  regions  of  the  body  contain  so  many  and  such  diverse  structures 
compressed  into  so  small  an  area.  There  is  here  a  labyrinth  of  tendons, 
nerves,  vessels,  and  fascise — to  say  nothing  of  tendon-sheaths,  small 
muscles,  and  bones.  All  these  structures  are  essential  to  the  proper 
use  of  the  hand — that  wonderful  piece  of  mechanism.  We  cannot  go 
roughly  slashing  into  it  without  crippling  it,  yet  to  get  out  the  pus  we 
must  in  a  fashion  slash. 

It  used  to  be  taught  as  a  safe  rule,  and  those  who  so  taught  were 
in  the  main  correct,  that  when  cutting  into  the  palm  one  should  make 
incisions  short,  multiple,  and  parallel  to  the  bones,  thus  avoiding,  so  far 
as  possible,  the  delicate  structures  of  the  hand.  That  plan  is  not  a 
bacl  plan — indeed,  it  is  the  one  commonly  followed  still,  but  it  has  this 
disadvantage,  that  through  these  straight  incisions  the  pus  is  sought 
somewhat  blindly  and  with  difficulty,  while  the  incisions  tend  to  early 
closure,  thus  damming  in  the  discharges  and  necessitating  a  second 
operation  often.  Moreover,  such  wounds  heal  with  disabling  scars, 
which  are  bound  closely  to  the  underlying  parts  and  seriously  limit 
motion. 

My  colleague,  W.  A.  Brooks,  Jr.,  has  devised  an  incision  which  I 
prefer.  The  patient  is  etherized.  While  his  hand  is  held  firmly  out- 
spread, we  outline  a  semicircular  flap  which  includes  the  whole  of  the 
palm  practically.  Enter  the  knife  over  the  second  metacarpophalan- 
geal joint,  and  after  sweeping  it  round  the  palm,  bring  it  out  at  the 
base  of  the  thenar  eminence;  in  other  words,  the  flap  is  to  be  turned 
back  on  the  thumb  as  a  pivot.  Rapidly  dissecting  away  the  skin, 
we  now  expose  completely  the  palmar  fascia.  A  little  pus  oozes  through 
it  at  various  openings.  Enlarge  the  openings  with  a  blunt  scissors  and 
rapidly,  without  damage  to  structure,  follow  up  and  clean  out  all  the 
cavities.  Thus  we  have  dealt  with  a  really  beautiful  and  well-exposed 
dissection  of  the  palm,  and  have  avoided  easily  the  important  arteries, 
nerves,  and  tendons,  for  we  have  seen  them,  and  we  have  searched  out 
the  burrowing  pus  far  more  thoroughly  than  was  possible  by  the  old 
blind  method.     Now  disinfect  carefully  the  whole  hand. 

As  for  drainage  and  the  after-treatment : 

Wicks  are  led  out  from  all  the  pockets;    a  thin  layer  of  gauze  is 


felon;  whitlow;  paronychia;  palmar  abscess 


751 


spread  over  the  whole  exposed  surface,  and  the  skin-flap  is  laid  back 
over  the  gauze.  In  the  subsequent  dressings,  when  necessary,  the 
skin-flap  maj^  again  be  turned  aside  and  the  depths  of  the  wound  may 
again  easily  be  explored.  Judging  by  experience,  we  should  find  the 
inflammation  subsiding  in  a  day  or  two,  when  the  wicks  gradually  will 
be  removed.  By  the  end  of  a  week  the  palm  and  the  under  surface  of 
the  flap  will  be  covered  with  granulations.  Then,  if  all  looks  clean  and 
sound,  we  stitch  the  skin  back  into  place  and  look  for  a  rapid  healing 
by  a  delayed  first  intention.  To  facilitate  the  sewing  back  of  the  flap 
we  usually  pass  so-called  provisional  stitches  at  the  time  of  the  original 
operation.     When  the  time  comes,  they  will  be  tied. 


Fig.  463. — Brooks'  incision  for  palmar  abscess. 

For  the  first  four  or  five  days  it  is  well  to  dress  the  hand  and  fore- 
arm in  a  large  creolin  poultice  with  a  splint,  but  this  may  be  abandoned 
soon  for  the  gauze  dressing  with  elastic  compression  and  elevation. 

One  is  surprised  to  see  how  useful  and  comely  a  hand  will  result 
from  all  this.  The  scar  will  be  there,  of  course,  but  it  will  not  be  especi- 
ally troublesome,  and  the  function  of  the  hand  will  generally  be  much 
better  than  was  the  case  when  multiple  Hnear  incisions  were  used._ 

Again,  let  me  warn  the  reader,  that  in  spite  of  what  I  have  said  of 
a  flap  at  the  thenar  eminence  one  must  never  operate  by  rule  of  thumb. 
Broadly,  this  operation  is  a  good  operation,  but  diverse  conditions  will 
present  themselves.  No  two  cases  are  alike,  and  while  one  must  strive 
always  to  observe  general  principles,  he  must  apply  also  a  broader 
common  sense. 


752  MINOR   SURGEUY — DISEASES   OF    STKLCTUHE 

BOILS;   CARBUNCLES 

Boils. — The  treatment  of  boils  ma}-  seem  to  be  a  very  minor  part 
of  minor  surgery,  yet  there  are  few  curable  conditions  more  trouble- 
some than  furunculosis. 

Some  months  ago  there  came  to  see  me  a  man  who  is  the  chief  of 
police  in  a  town  near  Boston.  He  had  upon  the  back  of  his  neck  two 
boils  and  the  scars  of  half  a  dozen  others.  For  four  months  he  had 
boon  suffering  from  these  pests — in  constant  discomfort,  with  a  sore 
and  painful  neck;  his  sleep  broken,  his  appetite  impaired,  and  his 
health  ])ccoming  undermined.  On  inquiry  I  learned  that  he  had  gone 
ten  }-ears  without  a  day's  vacation,  and  that  for  six  months  l)efore  the 
appearance  of  his  boils  he  had  been  feeling  nin-down  and  debilitated 
from  that  condition  of  faulty  metabolism  w^hich  we  call  muscular 
rheumatism. 

I  gave  him  a  simple  cleansing  wash  for  the  neck  and  a  course  of 
aperient  waters.  I  enjoined  a  two  weeks'  vacation,  and  the  following 
tonic :  sulphate  of  iron,  2  drams ;  sulphate  of  magnesia,  6  drams ;  dilute 
sulphuric  acid,  6  drams;  syrup  of  ginger,  4  drams;  water,  9  drams. 
The  dose  is  one  teaspoonful  in  water  after  meals.  To  the  boils  I  applied 
a  soft  protective  cotton  dressing  merely.  Ten  days  later  the  man  wrote 
to  me  that  his  boils  had  disappeared  and  that  he  was  feeling  well. 

That  case  illustrates  one  of  the  most  important  points  one  must 
make  in  this  connection.  It  is  the  point  I  have  so  often  made  before. 
We  must  regard  the  patient's  general  condition.  And  boils  are  usually 
a  manifestation  of  a  general  condition.  They  indicate  some  form  of 
malnutrition,  and  must  be  treated  on  that  basis. 

Billings'  Dictionary  defines  a  boil  as  "&  painful  conic  or  rounded 
swelling  of  the  skin,  due  to  inflammation  about  a  hair-follicle,  a  Mei- 
bomian gland,  or  a  sweat-gland."  That  is  a  fair  enough  definition, 
and  if  we  turn  to  page  172  of  Warren's  Surgical  Pathology  we  shall 
find  the  nature  of  the  process  exhaustively  described.  The  point  of 
it  all,  so  far  as  the  clinician  is  concerned,  is  that  the  organisms  normally 
present  in  the  skin  gain  lodgment  in  some  of  the  glands  or  ducts  and 
then  multiply.  The  active  development  of  these  colonies  of  bacteria 
produces  small  areas  of  connective-tissue  necrosis.  This  necrotic  por- 
tion acts  as  a  foreign  body,  and  nature  proceeds  to  throw  it  off  as  a 
"core."  The  process  of  throwing  it  off  gives  rise  to  further  inflamma- 
tion, with  the  resulting  pus-formation  and  swelling.  After  the  core 
is  thro'\\"noff,  there  remains  a  little  pit,  which  must  heal  by  granulation. 
So,  we  see,  there  are  three  stages  in  the  life  history  of  a  boil,  and  each 
stage  demands  its  appropriate  treatment.  There  is  the  first  stage, 
when  we  see  a  small  superficial  pustule  only;  the  second  stage,  when 
we  see  a  much  larger  mass — elevated,  indurated,  and  ])ainful,  containing 
its  core;   and  the  third  stage  of  a  crater-like  but  subsiding  swelling. 

Commonly,  a  patient  comes  to  the  surgeon  with  a  well-developed 
boil  in  the  second  stage,  and,  in  its  neighborhood,  two  or  three  incipient 
boils  or  pustules.     If  the  case  is  a  chronic  one,  make  up  your  mind 


boils;  carbuncles  753 

about  the  patient's  general  condition,  especially  as  regards  diabetes 
and  rheumatism. 

Take  another  patient  as  a  good  example  of  what  we  are  describing. 
He  is  a  night  watchman  whose  daytime  sleep  is  disturbed.  He 
is  given  to  rather  excessive  whisky  drinking,  and  is  feeling  pretty 
well  "  done  up."  He  has  a  poor  appetite,  constipation,  a  furred  tongue, 
and  is  a  striking  type  of  the  tired  man  who  is  burning  the  candle  at  both 
ends.  I  need  not  trouble  you  with  details  of  general  treatment  in  his 
case  except  to  say  that  we  should  stop  his  liquor,  and  give  him  a  course 
of  Carlsbad  salts,  with  5  grains  of  Blaud's  pill  before  his  meals.  Look- 
ing now  at  the  back  of  his  neck,  we  see  on  the  right  side  a  conic  sweUing 
the  size  of  a  silver  ''quarter."  It  is  reddened  at  the  center,  where  it 
is  beginning  to  break  down  and  soften,  but  everpvhere  else  it  is  indur- 
ated. It  is  very  tender  to  the  touch,  painful  on  pressure,  and  the 
man  says  it  ''feels  sore  all  round."  To  the  left  of  it  are  three  little 
pustules,  with  reddened  areolae,  each  about  half  the  size  of  one's  little 
finger-nail.  In  the  first  place,  as  regards  these  incipient  boils,  let  me 
assert  with  much  assurance  that  they  may  be  aborted.  The  old- 
fashioned  method  was  to  poultice  the  back  of  the  neck  and  bring  the 
whole  crop  "to  a  head."  Do  not  do  it.  There  are  scoffers  who  will 
say  that  boils  cannot  be  aborted.  I  doubt  if  they  have  tried  faithfully 
any  method.  Here  are  two  methods.  One  may  prick  the  little  pustule 
and  wipe  out  the  minute  cavity  with  a  probe  dipped  in  pure  carbohc 
acid.  That  often  will  suffice,  but  I  have  not  found  it  so  successful  as 
the  hypodermic  injection  of  very  small  quantities  of  some  strong  anti- 
septic. 

In  the  first  place,  we  cleanse  the  neck  with  soap  and  water  and 
alcohol.  Then  inject  5  or  6  minims  of  cocain,  in  4  per  cent,  solution, 
under  the  infected  areas.  Now  into  this  anesthetized  zone,  along  the 
cocain  track,  inject  under  each  pustule  2  minims  of  pure  styron— an 
ancient  but  efficient  balsamic  antiseptic.  I  prefer  it  to  carboHc  acid, 
because  more  thoroughly  it  permeates  the  affected  tissues.  The  result 
of  this  injection  is  to  destroy  the  active  bacteria  and  to  convert  the 
infected  area  into  an  aseptic  eschar.  The  immediate  outcome,  so  far 
as  the  patient  is  concerned,  is  that  the  sense  of  burning  and  discomfort 
disappears  in  a  few  minutes;  without  further  sensation,  the  eschar  is 
thrown  off  and  the  Httle  wound  heals  up.  Remember  to  use  cocain 
before  these  injections  of  styron,  for  the  styron  used  without  such  pre- 
liminary treatment  causes  a  few  moments  of  severe  pain. 

I  am  satisfied,  from  a  fairly  wide  experience  with  this  method  of 
aborting  boils,  that  it  will  usually  be  found  successful.  A  young  man 
consulted  me  recently  who  had  pustule  after  pustule  appear  on  his 
neck  for  a  period  of  several  weeks.  One  of  them  ran  a  severe  course 
and  had  to  be  opened  and  cureted  twice.  Into  the  other  incipient 
furuncles— perhaps  a  dozen  or  more,  as  they  appeared  from  week  to 
week— I  injected  styron  and  checked  them  at  once.  Finally,  with 
tonics  and  general  treatment,  the  malady  subsided.^ 

1  In  these  cases  I  think  highly  of  opsonic  vaccines  (Staphylococcus  aureus). 
48 


754  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

There  is  another  method  of  treatment  which  another  patient,  a 
medical  student,  illustrates.  He  luul  a  slightly  septic  finger,  which 
healed  without  trouble,  but  he  became  "  run  down "  and  developed 
a  crop  of  boils  on  his  left  arm.  They  were  treated  by  his  friends  and 
the  surgeons  in  various  dispensaries,  where  he  kept  at  his  work.  They 
were  opened,  injected,  poulticed,  time  after  time,  but  continually  re- 
curred until  he  became  discouraged  and  his  life  became  a  burden.  I  had 
seen  him  several  times,  but  was  unable  to  check  the  process,  and  there 
seemed  to  be  nothing  for  it  but  to  send  him  away  on  a  long  vacation. 

Finally,  when  he  came  here  I  determined  to  take  a  leaf  from  the 
book  of  my  friend,  H.  L.  Burrell,  and  try  the  effect  of  a  carefull}^  applied 
Gamgee  dressing.  At  that  time  the  forearm  had  on  it  three  incipient 
boils  and  the  healing  scars  of  a  half-dozen  others.  The  arm  was  care- 
fully disinfected,  wrapped  in  absorbent  gauze,  and  put  up,  from  fingers 
to  shoulder,  in  our  wadding  and  mill-board  apparatus,  with  firm  com- 
pression.    A  sling,  of  course,  completed  the  equipment. 

That  dressing  was  put  on  one  Friday  and  remained  undisturbed 
until  the  following  Tuesday.  I  then  removed  it,  to  find  the  arm  clean 
and  shrunken,  the  little  red  boils  shriveled,  and  the  old  scars  practically 
sound.  That  was  an  interesting  experiment,  and  certainly  it  shows 
in  a  most  striking  manner  the  ever-present  value  of  our  familiar  first 
principles — support,  immobilization,  elevation. 

When  a  boil  has  developed  fully,  or  "  come  to  a  head,  "  as  the  saying 
is,  the  treatment  is  simple  and  obvious.  There  is  then  no  special  in- 
terest in  it.  We  must  open  it  and  clean  it  out.  Cocainize  it  first,  of 
course,  by  one  or  two  deep  injections  along  its  borders.  Make  a  crucial 
incision  or,  what  is  better,  excise  a  little  cone  at  its  apex,  about  half  as 
large  as  a  silver  dime.  This  excision  will  usually  bring  with  it  the  core. 
Then  scrape  the  cavity  clean  and  drain  it  with  a  bit  of  gauze.  For  a 
day  or  two  a  creolin  poultice  will  be  a  great  comfort  to  the  patient; 
after  that,  until  the  wound  is  healed,  a  cotton  dressing  is  convenient 
and  comfortable.  One  little  note :  never  plaster  a  cotton  dressing  down 
with  adhesive  strapping.  It  is  dirty  and  inefTective  compared  with 
collodion,  and  the  taking-off  process  is  painful.  The  collodion  dressing 
may  always  easily  be  soaked  off  with  alcohol. 

Carbuncle. — When  we  come  to  deal  with  carbuncles,  we  have  a 
quite  different  problem — different  in  the  extent  and  gravity  of  the 
process,  but  not  so  different  in  its  causation  and  development. 

Observe  two  patients.  The  first,  a  woman,  has  below  the  occipital 
protuberance,  and  above  the  line  of  her  hair,  a  conic  swelling  about 
the  size  of  a  silver  dollar.  Part  the  hair  and  expose  the  swelling,  when 
we  note  that  its  apex  has  an  excoriated  look,  and  that  there  are  three 
little  craters  from  which  a  drop  or  two  of  pus  may  be  squeezed.  The 
little  mass  is  brawny  to  feel  and  is  quite  deeply  seated.  Take  it  as  a 
whole,  however,  it  resembles  closely  a  boil,  and  one  might  readily  mis- 
take it  for  a  boil.     It  is  a  carbuncle  in  its  early  stages. 

In  comparison,  the  process  in  the  second  patient,  a  man,  is  much 
further  advanced.     It  is  in  the  common  location  on  the  back  of  the 


boils;  carbuncles 


755 


neck,  on  the  left  side,  below  the  line  of  the  hair,  and  to  look  at  appears 
to  be  as  large  as  the  top  of  a  small  tea-cup;  when  we  handle  it,  how- 
ever, it  is  found  to  be  deeply  seated,  with  a  widely  indurated  base, 
nearly  as  large  as  one's  palm,  about  it.  It  is  flattened  at  its  top  and 
has  a  half-dozen  little  craters  from  which  pus  oozes  and  bits  of  white 
sloughs  protrude.     That  is  a  large  carbuncle.     Both  patients  are  de- 


Fig.  464. — Excision  of  carbuncle. 

bilitated — the  woman  from  a  week's  pain  and  discomfort,  the  man  from 
nearly  three  weeks  of  a  similar  experience.  Both  cases  are  uncompli- 
cated. The  urines  are  free  from  sugar;  both  patients  are  in  their  prime 
and  of  previous  good  health. 

^Tiat  is  a  carbuncle  and  wherein  does  it  differ  from  a  boil? 

Billings'  Dictionary  defines  carbuncle  as  "A  circumscribed  inflam- 
mation of  skin  and  subcutaneous  connective  tissue,  terminating  in  a 
slough."     More  than  that,  it  is  usually  a  gangrenous  inflammation.     It 


■756  MINOR   SURGERY — DISEASES   OY   STRUCTURE 

begins  on  the  skin,  us  does  a  boil,  but  it  spreads  much  deeper  and,  as  one 
would  expect,  it  is  produced  by  the  Staphylococcus  pyo<renes  albus 
and  aureus.  Do  not  confuse  this  process  with  anthrax,  as  did  liillroth 
and  the  older  pathologists.  Anthrax  has  many  of  the  appearances  of 
carbuncle,  but  it  is  far  more  rapid,  it  has  a  wide  reddened  zone  about  it, 
it  has  not  the  characteristic  elevated  flattened  surface,  it  is  nearly 
covered  with  a  gangrenous  eschar,  and  it  is  caused  by  the  Bacillus 
anthracis. 

The  characteristic  carbuncle  begins  then  as  a  superficial  skin  inflam- 
mation about  a  hair-follicle  or  gland,  and  works  rapidly  downward 
along  the  colnmnce  adiposcv  into  the  connective  tissue;  there  it  spreads 
rapidly,  involving  other  colu nines  and  other  glands,  pressing  upward 
all  the  time,  elevating  the  overlying  skin,  finding  numerous  points  of 
exit,  and  causing  extensive  necrosis  of  the  connective  tissue  which  it 
involves.  It  is  usually  a  local  process,  but  rarely  it  may  destroy  the 
dense  aponeurosis  of  the  underlying  muscles  and  extend  widely-  to  other 
structures.  When  we  find  it  in  its  usual  seat  on  the  back  of  the  neck, 
we  need  not  fear  it  greatly,  for  tough  structures  limit  it  below,  but  when 
situated  in  regions  of  greater  vascularity  and  more  delicate  composition, 
as  on  the  cheek  and  lip,  it  may  spread  rapidly,  cause  serious  disfigure- 
ment, and  even  threaten  life. 

Let  me  say  a  very  decided  word  about  treatment  in  these  two  cases 
before  us.  There  is  one  method,  and  that  method  is  nearh'  always 
sure  and  final — excise  the  carbuncle.^  Do  not  dally  with  applications 
and  poultices  or  even  with  the  old-time  deep  crucial  incisions.  They 
imply  delay,  if  they  do  not  cause  an  extension,  of  the  process.  The 
necrotic  mass  in  each  case  must  come  out.  If  we  poultice  or  incise, 
we  do  not  prevent  a  loss  of  substance — substance  has  been  lost  already. 
It  is  far  better  thoroughly  to  excise  it  at  once. 

Take,  as  our  best  example  the  man  with  the  large  inflammation. 
He  is  etherized,  for  the  operation  is  a  considerable  one,  and  the  knife 
is  carried  cleanly  and  completely  around  the  carbuncle,  outside  of  the 
necrotic  area.  The  blade  bites  do^^^l  to  the  underlying  fascia,  and  the 
whole  sloughing  mass  is  dissected  out.  The  bleeding  is  checked,  the 
cavity  packed  with  absorbent  gauze,  and  the  Avound  left  to  granulate. 
When  we  look  at  the  size  of  it,  we  exclaim  perhaps  that  here  is  a  need- 
less sacrifice  of  tissue,  and  that  the  resulting  scar  will  l)e  enormous. 
One  will  be  surprised,  in  the  course  of  two  or  three  weeks,  to  see  how 
the  sound  parts  have  come  together,  and  how  trifling,  after  all,  will  be 
the  evidence  left  of  the  great  wound.  It  is  interesting  also  to  hear  the 
patient's  own  account  of  himself  the  next  day.  The  old  incisions 
gave  but  little  relief  at  the  time;  the  excisions  are  followed  by  an  almost 
immediate  reaction;  and  when  next  the  man  comes  in  we  expect  to 
hear  from  him  that  he  has  passed  a  good  night,  has  eaten  a  hearty 
breakfast,  and  is  practically  free  from  pain. 

Don't  coquette  with  a  carbuncle.  Cut  it  out  as  you  would  a- cancer, 
and  you  will  never  regret  it. 

1  In  the  case  of  carbuncles  the  opsonins  cure  often. 


bunions;  ingrowing  nails;  corns;  and  warts  757 

BUNIONS;   INGROWING   NAILS?   CORNS;  AND  WARTS 

Bunion. — Bunion  is  a  condition  frequently  associated  with  liallex 
valgus.  Hallex  valgus,  an  extreme  deformity  and  outward  displace- 
ment of  the  great  toe,  was  for  centuries  called  hallux  valgus.  As  such 
one  finds  it  described  in  all  the  books  on  surgery.  Robert  H.  M.  Daw- 
barn,  of  New  York,  w^as  the  first  to  point  out  the  error,  and  that  was  but 
a  few  years  ago.  The  word  hallex  itself  is  archaic.  It  means  literally 
a  scoundrel;  and  you  shall  search  your  dictionaries  to  find,  at  last, 
"Allex  (hallex)  in  Isid.  Gloss,  est  pollex  pedis." 

However  all  that  may  be,  bunion  is  a  good  Greek  word..  A  bunion  is 
an  inflamed  bursa,  situated  usually  to  the  inner  side  of  the  metatarso- 
phalangeal joint  of  the  great  toe,  and  if  it  becomes  inflamed,  it  makes 
trouble.  Persons  who  go  barefoot  or  wear  sandals  do  not  have  bunions, 
but  if  one  puts  a  foot  into  an  ill-fitting  boot  and  crowds  it  forward,  the 
great  toe  will  feel  the  impact  and  be  thrown  outward  across  the  second 
toe.  Sometimes  the  deformity  is  so  extreme  that  the  great  toe  appears 
to  be  at  right  angles  to  the  axis  of  the  foot. 

When  this  deformity  takes  place,  the  toe  is  partially  dislocated  at 
the  metatarsal  joint,  and  upon  the  knuckle  so  formed  comes  the  constant 
pressure  of  the  side  of  the  boot.  Here  lies  the  bursa  over  the  knuckle, 
and,  as  a  result  of  the  pressure,  it  becomes  irritated,  thickened,  and 
inflamed.  The  condition  is  a  compound  one,  both  bone  and  bursa 
being  involved. 

Operate  by  making  a  sweeping  incision  about  the  dorsal  side  of  the 
joint,  and  turn  down  upon  the  sole  of  the  foot  the  flap,  which  is  about 
2  inches  in  diameter.  The  exposed  bursal  sac  we  next  open  and  dissect 
out.  It  is  distended  with  a  flocculent  fluid,  and  there  is  often  at  its 
base  a  little  opening,  which  leads  directly  into  the  joint.  This  illustrates 
an  important  point,  namely,  that  we  are  never  safe  in  operating  hastily 
upon  a  bunion,  for  we  cannot  always  tell  beforehand  whether  or  not  it 
may  communicate  with  the  joint.  Every  surgeon  has  had  patients 
come  to  him  from  ignorant  "corn  doctors,"  who  have  attempted  to 
pare  off  one  of  these  bunions,  with  a  resulting  opening  in  the  joint  and 
a  severe  septic  arthritis. 

Following  up  such  a  sinus,  lay  open  the  joint,  of  which  the  ligaments 
are  so  relaxed  from  the  inflammation  that  their  function  is  destroj^ed, 
the  phalanx  being  in  a  state  of  subluxation.  The  joint  cavity  is  found  to 
contam  some  of  the  fluid  that  we  saw  in  the  bursa,  and  the  articulating 
surfaces  are  roughened  and  diseased;  in  other  words,  we  have  shown 
that  apparently  simple  thing  called  a  bunion  to  be  an  extensive  disease 
of  bursa,  joint  surface,  and  bone. 

There  is  no  possibility  of  success  from  palliative  measures  in  such  a 
case.  The  toe  cannot  be  straightened,  even  with  the  joint  laid  open. 
The  only  thing  to  do  is  to  excise  the  end  of  the  metatarsal.  This  we  do 
accordingly,  with  the  chain  saw,  and  find  that  the  normal  line  of  the 
great  toe  now  can  easily  be  restored.  The  rest  of  the  treatment  follows 
naturally.     Bleeding  is  checked,  and  the  deep  parts  over  the  joint 


758  MINOR    SURGERY — DISEASES   OF   STRUCTURE 

are  closed  with  buried  catgut  sutures,  in  order  that  the  false  joint  at 
which  we  aim  may  have  a  firm  lateral  support.  Those  deep  buried 
stitches  are  essential  for  success.  The  skin-flap  is  then  stitched  into 
place  and  the  toe  is  held  in  its  new  straight  jjosition  by  a  light  tin  splint. 
Over  all  is  wrapped  firndy  a  wadding  and  mill-board  dressing  to  the 
knee,  and  the  patient  is  put  to  bed.  By  the  end  of  the  week  we  take 
the  dressing  down  and  hope  to  show  a  soundly  healed  wound. 

The  above  case  was  an  extreme  one.  Hallex  valgus  is  its  con- 
spicuous feature,  but  consider  a  couple  of  simpler  cases  which  admit 
of  simpler  treatment.  Both  have  a  slight  outward  bend  of  the  toe 
and  an  inflamed  tender  bursa  or  ])union  on  the  inner  side.  The  first 
patient,  a  woman,  has  a  toe  which  is  easily  pulled  back  into  place.  We 
content  ourselves  with  ordering  a  proper  pair  of  broad,  square-heeled, 
laced  boots,  with  straight  sole  on  the  inner  side.  Over  the  bunion  fit  a 
piece  of  felt,  cut  like  a  large  corn-plaster.  That  will  protect  the  bursa 
from  pressure,  and  the  properly  made  boot  will  allow  the  slight  de- 
formity of  the  toe  to  correct  itself.  Such  cases  are  frequently  associated 
with  a  breaking-down  of  the  longitudinal  arch  of  the  foot  and  a  conse- 
quent flat-foot,  but  that  is  another  story. 

The  second  patient,  a  man,  has  a  hallex  valgus  and  a  l^union  similar 
to  the  woman's,  but  the  toe  is  not  so  readily  pulled  into  place.  For 
him  we  arrange  a  hard-rubber  spoon  splint.  The  bowl  of  the  spoon 
has  a  handle  at  either  end.  When  the  padded  bowl  is  laid  over  the 
bunion,  the  upper  handle  extends  along  the  side  of  the  foot  and  the 
lower  along  the  toe.  With  the  upper  handle  strapped  into  place  pull 
the  toe  inward  toward  the  lower  handle,  and  so  correct  the  deformity. 
By  his  wearing  this  simple  apparatus  for  a  few 
weeks,  and  by  the  fitting  of  a  proper  boot,  we 
hope  permanently  to  correct  the  deformity. 

Another  crippling  affection  of  the  foot  is 
ingrowing  toe-nail.  This  also  is  a  disease 
peculiar   to    civilized    peoples  who    are   boot- 

^.              ^  wearers,  and  is  not  seen  in  those  who  go  bare- 
Fig.  46.3. — transverse  r      .     i 
section  through  phalanx  of  looted. 

great  toe,  showing  ingrow-  Years  ago  an  old  armv  surgeon  told  the 

ing  toe-nail  and  mass  of  ^^.j^^^^.  ^^^^  ^^^  j^^j  ^^^  trouble  with  ingrowing 
granulation  tissue    (row-  •        .,  .  .  r^        i       i      i    .         il 

ler,  after  Hueter).  toe-naus  among  his  men  alter  he  had  taught 

them  how  properly  to  trim  their  nails.  They 
were  to  cut  them  straight  across  instead  of  making  a  rounded  comer. 
We  have  found  that  t^imple  maneuver  to  be  a  valuable  prophylactic 
measure. 

The  common  seat  of  ingrowing  nail  is  on  the  outer  side  of  the 
great  toe.  As  with  bunion,  it  is  due  to  ill-fitting  or  tight  boots.  A 
case  will  illustrate  the  usual  story.  A  young  woman  noticed  that 
the  outer  side  of  her  toe  began  to  feel  sore.  It  was  red  and  tender.  To 
relieve  the  discomfort  she  trimmed  the  nail  down  on  the  side.  That 
answered  well  enough  for  three  or  four  days,  but  by  the  excision  of  that 
strip  of  nail  the  pulp  was  given  so  much  the  greater  latitude  for  bulging 


bunions;  ingrowing  nails;  corns;  and  warts 


759 


inward.  It  continued  to  encroach  upon  the  nail,  became  irritated  and 
eroded  by  the  rough  nail  edge,  took  on  the  characteristics  of  a  chronic 
ulcer,  and  threw  out  exuberant  granulations,  which  overlapped  that 

side.     The  part  became  ex- 
1  -  quisitely    sensitive  to   pres- 

sure, and  a  little  pus  exuded 
,  from  under  the  granulations. 

I  \.  Nothing-short  of  an  opera- 

tion can  be  done.  Palliation 
is  useless.  There  are  two  or 
three  operations  of  value. 

Cotting's  operation  was 
devised  by  a  well-known 
Boston  surgeon.  It  consists 
of  passing  the  knife,  at  right 
angles  to  the  plane  of  the 
nail,  into  the  pulp,  and  shav- 
ing off  the  whole  of  the  soft 
parts,  together  with  a  nar- 
row sliver  of  nail  on  that 
side  of  the  last  joint  of  the 
toe.  The  wound  is  left  to 
granulate,  and  a  contracted 
scar  instead  of  normal  pulp 
is  the  result.  Ingrowing  nail 
cannot  occur  again  there, 
for  there  is  no  pulp  for  it  to 
grow   into.      The    operation 


Fig.  466. — Cotting's  operation  for  ingrowing  toe-nail. 

is  radical  and    effective,  but  leaves  the  patient  with  a,  sore  toe  for 

weeks.      Then  here  is  a  similar  operation  which  consists  of  cutting 

out  a  "piece  of  pie, "  as  it  were,  from  the  pulp  and  sewing  up  the  hole. 

A  third  useful  operation :   The  toe  being  cocainized,  seize  the  nail 


760 


MINOR    SURGERY — DISEASES   OF   STRUCTURE 


deeply  and  firmly  with  a  strong  pair  of  plying  forceps,  and  twist  it  out 
entire ;  then  curet  off  the  granulations.  At  the  end  of  several  months, 
when  the  new  nail  has  grown  out,  the  wounded  pulp  will  have  healed 
and  shrunk,  and  the  patient  will  then  be  as  though  no  trouble  had  ever 
been.  The  operation  is  simple,  the  laceration  is  shght,  and  the  resulting 
incapacity  of  very  brief  duration.  A  simple  vaselin  and  gauze  dressing 
is  all  that  is  required. 

Let  us  say  an  important  word  about  palliation  in  the  incipient  cases. 
Palliation  means  properly  fitted  boots,  and  the  packing  of  cotton 
under  the  nail.     If  one  pack  skilfully,  one  may  so  treat  a  fairly  bad  case. 


Fig.  467. — Packing  ingrowing  toe-nail. 

Few  men  do  so  pack.  Do  not  roughly  and  quickly  thmst  in  the  cotton. 
We  shall  grievously  hurt  the  patient,  and  will  not  get  the  cotton  in. 
With  the  patient's  foot  on  the  surgeon's  knee,  take  a  strand  of  absorbent 
cotton,  lay  it  by  the  side  of  the  nail,  use  the  back  of  a  narrow-bladed 
knife,  and  gently  and  patiently,  with  a  succession  of  pushes,  insinu- 
ate the  cotton  under  the  edge.  The  patient  will  experience  prompt 
relief.  Repeat  the  performance  once  a  week  until  a  cure  is  established. 
Corns  (Clavus). — A  few  months  ago  a  young  fellow  from  the  college 
in  Cambridge  came  to  me  complaining  that  he  had  run  several  splinters 
of  wood  into  his  foot  when  walking  barefooted  on  the  "float"  at  the 


bunions;  ingrowing  nails;  corns;  and  warts  761 

boat-house.  He  had  pulled  out  two  splinters  half  as  long  as  his  little 
finger,  but  a  third  had  been  healed  in  and  caused  him  constant  pain  in 
walking.  I  examined  the  foot,  and  could  distinctly  feel  the  foreign 
body,  as  large  as  a  medium  penknife  blade,  deep  under  the  skin  at  the 
base  of  the  second  toe.  There  seemed  no  reason  to  doubt  the  presence 
there  of  a  splinter.  I  made  an  incision  deeply  into  the  foot  and  went 
down  for  nearly  half  an  inch  through  a  stratum  of  tough  callus,  until 
I  reached  normal  tissue.  There  was  no  splinter  there.  The  seeming 
foreign  body  was  nothing  but  a  great  callus,  which  I  excised,  and  so 
cured  the  lad  of  his  painful  foot — but  I  had  learned  my  lesson. 

This  callosity  was  of  the  nature  of  a  corn,  which  is  made  up  of  a  cir- 
cumscribed excessive  development  of  the  epidermis  and  of  a  central 
portion  or  core.  The  core  extends  quite  deeply  into  the  tissues,  in  the 
form  of  an  inverted  cone,  the  base  being  directed  outward,  appearing 
on  the  surface  as  a  rounded  area,  the  apex  of  the  cone  resting  on  the 
papillary  layer  of  the  corium  and  causing  pain  when  pressed  upon. 
In  this  case  I  performed  a  radical  cure  in  the  only  manner  which  is 
possible,  namely,  by  excision.  Nothing  else  will  do  it.  The  "corn 
doctors"  do  not  wish  to  cure.  Their  palliative  measures  merely  relieve 
pressure  for  a  time,  but  the  patient  returns  repeatedly  for  further 
treatment. 

After  all,  few  patients  will  consent  to  so  radical  a  measure  as  excision, 
especially  with  the  prospect,  if  they  are  not  careful,  of  a  fresh  com 
developing  about  the  site  of  the  scar.  So  the  sufferer  comes  back  again 
and  again  to  parings  and  plasters,  and  will  continue  so  to  do  as  long  as 
boots  are  worn  and  corn  doctors  abound  in  the  land. 

As  regards  warts,  there  are  several  facts  which  one  should  bear  in 
mind  about  them.  There  are  four  principal  varieties:  The  ordinary 
homy  warts  of  children  (verraca  vulgaris),  the  smooth  multiple  warts 
on  the  faces  of  old  persons  (verruca  senilis),  the  little  worm-like  warts 
which  we  see  hanging  from  the  lids  (verruca  filiformis),  and,  lastly, 
venereal  warts  (verruca  acuminata).  There  is  reason  to  suppose  that 
all  these  varieties  are  due  to  some  infecting  organism,  though  this  is  not 
definitely  proved.  The  common  wart  of  children,  seen  mostly  on  the 
hands  and  fingers,  may  appear  and  disappear  in  an  inexplicable  manner. 
It  is  composed  of  a  papilla  containing  a  vascular  loop;  this  is  cov- 
ered by  a  very  much  thickened  homy  layer,  which  in  tum  is  covered 
by  a  hypertrophied  rete. 

Take  the  case  of  a  boy  with  three  such  homy  warts  on  his  fingers. 
One  we  pare  down  with  a  sharp  knife  and  touch  the  base  with  the  nitrate 
of  silver  stick ;  the  second,  after  paring,  we  touch  with  nitric  acid ;  and 
to  the  third  we  apply  a  mixture  of  salicylic  acid,  the  important  ingre- 
dient of  most  of  the  patent  "wart  cures."  It  contains  salicylic  acid, 
^  dram;  extract  cannabis  indica,  5  grains;  flexible  collodion,  ^  ounce. 
This  is  painted  on  the  wart  twice  a  day  for  five  clays  until  the  growth 
becomes  necrotic.  The  finger  is  then  soaked  for  fifteen  minutes  in  hot 
water,  when,  if  all  goes  well,  the  wart  will  drop  off. 

The  soft,  flat  waits  of  elderly  persons  are  permanent  and  are  not 


762  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

especially  disfiguring,  but  they  have  this  important  fact  connected 
with  them,  that  they  may  become  epitheliomata  of  a  malignant  type. 
The  patient  may  pick  at  one  until  it  bleeds  or  he  partially  dislotlges  it, 
when  he  finds  that  it  does  not  heal;  that  the  little  ulcer,  so  formed, 
spreads,  and  that  he  is  concerned  with  a  troublesome  sore.  When 
you  see  such  an  affaii-,  cut  it  out  first,  and  then  let  the  microscope  settle 
its  exact  nature. 

Those  offensive  looking  filiform  warts  which  we  see  hanging  from 
the  lids  and  necks  of  patients  may  be  very  simph'  treated.  A  snip  of 
the  scissors  and  a  touch  with  the  lunar  caustic  suffice  for  them. 

Then  there  are  the  venereal  warts  which  are  seen  upon  the  genitals 
and  are  due  to  sexual  contact.  The  patients  are  often  much  frightened 
and  think  the  warts  are  indicative  of  serious  venereal  disease;  l)ut  one 
can  assure  them  that  such  is  not  the  case.  The  growths  will  disappear 
if  washed  persistently  with  a  solution  of  tannin  in  alcohol,  one  dram  to 
three  ounces;  after  washing,  the  wart  is  dried  and  dusted  with  salicylic 
acid. 

After  all  is  said,  however,  these  various  forms  of  warts  seldom  make 
trouble,  and  their  treatment  ma}'  be  regarded  as  a  very  subordinate 
branch  of  cosmetic  surgery. 

MASSAGE 

We  began  this  chapter  by  describing  the  value  and  effect  of  immo- 
bilization. Let  us  now  discuss  the  value  of  motion  in  certain  injuries, 
of  motion  in  a  limited  sense  only — massage.  That  is  a  subject  about 
which  there  has  long  been  much  misconception  among  surgeons,  and 
even  to-day  this  useful  therapeutic  measure  is  availed  of  less  than  it 
deserves. 

Massage  is  no  new,  fanciful,  or  untried  thing.  It  is  one  of  the 
oldest  practices  in  medical  history,  and  is  referred  to  not  only  by  the 
earliest  writers  on  surgery,  but  by  poets  who  wrote  long  before  medical 
literature  began.  If  a  boy  bumps  his  shin,  he  rubs  it;  if  a  dog  bruises  his 
foot,  he  licks  it.  There  you  have  nature  prompting  to  a  primitive 
massage,  the  uses  of  which  have  been  elaborated  into  the  skilful  manipu- 
lations of  our  modern  experts. 

The  practice  of  massage  was  in  bad  odor  for  long  in  this  country 
because  of  the  preposterous  claims  of  its  many  ignorant  exponents 
and  the  frequent  danger  they  inflicted  upon  unsuitable  cases.  In  the 
course  of  years  all  that  was  changed :  educated  persons,  many  of  them 
trained  in  Sweden  and  France,  took  up  the  practice;  the  operators, 
both  men  and  women,  came  to  see  that  their  work  was  as  assistants  to 
surgeons  and  not  as  their  rivals,  until  to-day  we  find  a  considerable 
number  of  such  competent  persons  in  every  commimity.  Lately  there 
has  developed  a  curious  outcome  of  these  conditions.  A  so-called 
"school"  of  medicine  has  grown  up.  Its  followers  apply  to  them- 
selves the  meaningless  term  ''osteopathists, "  and  they  essay  on  their 
own  responsibility  various  forms  of  massage. 

Students  often  ask  their  instructors  how  thev  can  learn  about  the 


MASSAGE  763 

methods  of  massage  and  whom  they  shall  employ,  and  I  find  there  is 
much  misconception  as  to  the  limits  of  its  usefulness.  A  common 
error  also  is  to  suppose  that  any  nurse  or  orderly  can  learn  to  give  it 
well  after  a  short  course  of  instruction.  I  believe,  other  things  being 
equal,  that  the  best  masseuse  may  be  developed  out  of  the  trained 
nurse,  but  I  affirm  that  the  best  masseuse  can  remain  the  best  by  con- 
stant practice  only.  The  tactile  sense  required  is  quickly  lost  if  allowed 
to  rust,  and  the  strong,  lithe  muscles  of  the  skilled  workman  become 
inexpert  and  feeble  when  long  unused.  Constant  practice  is  as  essential 
to  the  masseur  or  masseuse  as  to  the  pianist,  the  artist,  or  the  football 
player.  The  professional  model  will  pose  immovable  for  an  hour,  if 
need  be,  before  the  "life  class"  in  the  studio;  but  I  am  told  of  the 
strong  man  Sandow  being  asked  to  pose  in  one  of  our  art  schools  re- 
cently, and  how,  after  enduring  the  strain  for  ten  minutes,  he  was  forced 
to  drop  his  arm  in  exhaustion  and  chagrin.  The  average  nurse  can 
give  excellent  rubbings  and  friction  when  required,  but  when  we  want 
proper,  expert  massage,  we  must  go  to  a  specialist  who  does  nothing 
else. 

Let  us  consider  some  of  the  conditions  in  which  massage  is  valuable 
to  the  surgeon.  One  of  the  commonest  of  injuries — an  injury  for  long 
a  reproach  to  our  art — is  sprained  ankle.  It  was  the  practice  up  to 
fifteen  years  ago — and  the  practice  is  still  followed  by  the  indifferent — 
to  immobilize  sprained  joints.  The  result  was  that  patients  so  treated 
were  tied  to  crutches  for  weeks  or  months,  the  time  depending  on  the 
severity  of  the  sprain— and  after  the  splint  and  crutches  were  thrown 
aside,  they  limped  about  as  cripples  for  an  indefinite  period.  It  used 
to  be  a  common  saying  that  a  man  must  expect  to  feel  his  sprain  occa- 
sionally for  the  rest  of  his  life,  even  if  he  be  not  left  wdth  a  joint  perma- 
nently stiff  and  painful.  That  such  were  the  results  sometimes  seen, 
every  surgeon  of  twenty  years'  experience  can  tell  you.  A  recent 
writer  has  said :  "  Supposing  a  prize  of  ten  thousand  dollars  were  offered 
for  the  quickest  way  to  make  a  well  joint  stiff,  what  more  effectual 
means  could  be  resorted  to  than  first  to  give  it  a  wrench  or  sprain,  and 
then  do  it  up  in  a  fixed  dressing  so  that  the  resulting  inflammation 
would  have  an  opportunity  of  producing  adhesions  of  the  parts?"  ^ 

Consider  the  patient  who  has  slipped  from  the  curbstone  and  "  turned 
his  ankle  "  while  running  for  a  street-car,  and  on  rising  has  found  him- 
self unable  to  stand  or  walk  without  agony.  He  is  carried  home,  and 
shortly  after  the  removal  of  his  boot  finds  that  his  ankle  is  swollen,  dis- 
colored, and  very  painful. 

The  one  important  lesion  which  we  have  to  distinguish  from  simple 
sprain  of  the  ankle  is  Pott's  fracture — which  you  know  to  be  a  fracture 
of  the  fibula  just  above  the  malleolus,  with  eversion  of  the  foot  and 
rupture  of  the  internal  lateral  ligament.  Palpation  of  the  sprained 
ankle  shows  us  no  such  fracture,  and  the  re -ray  plate  demonstrates  sound 
bones  of  the  leg  and  tarsus. 

But  what  do  we  see  and  feel?  The  foot  is  swollen  and  boggy,  especi- 
^  A  Treatise  on  Massage,  by  Douglas  Graham,  M.D. 


764  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

ally  over  the  internal  malleolus,  and  the  skin  is  stained  a  pale  yellow 
from  extravasated  blood  and  serum.  Doubtless  the  man  violently 
wrenched  his  foot,  bruising  the  sjTiovia  of  the  joint  surfaces,  stretching 
and  bruising  the  tendons  and  tendon-sheaths,  and  tearing  a  few  of  the 
fibers  of  the  lateral  ligament.  As  a  result  there  has  been  a  certain 
amount  of  escape  of  blood  from  the  damaged  soft  parts;  and  a  serous 
exudate,  stimulated  by  the  increased  flow  of  blood  to  the  part,  is  nature's 
primary  attempt  to  repair  damages.  The  exudate  has  infiltrated  the 
tissues,  with  a  resulting  discoloration.  As  time  goes  on  the  exudate 
will  settle  out  more  and  more  toward  the  surface,  and  the  staining  of 
the  skin  will  become  darker,  until,  by  the  end  of  four  or  five  days,  we 
shall  see  the  skin  over  the  dorsum  deeply  pigmented  and  the  ecchy- 
mosis,  following  the  tendons  and  muscle  interspaces,  appearing  well  up 
on  the  calf. 

Here  then  is  our  problem :  Shall  we  leave  all  this  exudate  to  remain 
quiet  and  to  organize  and  cause  adhesions  of  tendon  and  joint  sur- 
faces, thus  impeding  the  circulation  and  impairing  the  nutrition  of 
the  parts?  or  shall  we  endeavor  to  remove  the  exudate  and,  by  stimu- 
lating the  circulation,  promote  repair  and  the  re  establishment  of 
function?  We  have  learned  the  results  of  the  former  practice.  The 
masseur  demonstrates  the  alternative. 

The  patient's  leg  is  bared  to  the  hip,  so  that  there  shall  be  nothing 
to  constrict  or  impede  the  circulation  as  he  lies  upon  the  examining 
table.  Observe  the  operator  begin  his  manipidations  gently  and  at  a 
distance  from  the  joint.  It  is  a  pretty  sight  to  watch  the  work  of  an 
expert.  He  kneads  and  rolls  the  muscles  of  the  calf,  urging  always  the 
return  flow  of  lymph  and  venous  blood  away  from  the  ankle.  Shortly 
the  circulation  begins  to  improve.  The  puffy,  indurated  "feel"  of  the 
leg  is  less  pronounced,  and  the  pain  diminishes  in  the  area  worked 
upon  as  the  exudate  is  forced  along  into  the  lymph-spaces  where  the 
stimulated  current  is  beginning  to  take  it  up  and  carry  it  on  into  the 
general  circulation.  Gradually  the  manipulations  are  carried  into  the 
region  of  the  damaged  joint;  the  toes,  the  sole,  and  the  dorsum  of  the 
foot  receive  their  share  of  attention,  until  the  operator  is  actually  rub- 
bing and  kneading  upon  the  joint  itself,  where,  half  an  hour  ago,  the  pain 
and  tenderness  were  so  great  that  the  patient  could  scarcely  endure 
the  weight  of  the  examining  hand.  Having  thus  kneaded  and  stimu- 
lated the  parts,  and  diminished  the  pressure  so  that  the  painful  disten- 
tion is  no  longer  so  apparent,  put  up  the  foot  in  a  carefully  applied 
flannel  bandage  from  toes  to  knee,  and  allow  the  patient  to  walk  with 
the  aid  of  his  crutches.  He  finds  that  he  can  now  bear  some  weight 
upon  his  lame  foot.  This  treatment  is  repeated  daily  for  a  week  or  ten 
days,  by  the  end  of  which  time  the  man  should  be  well. 

We  must  bear  in  mind  that  complications  may  be  looked  for  in  these 
joint  injuries  and  may  call  for  treatment.  One  of  the  commonest  of  them 
is  acute  articular  "rheumatism,"  in  those  persons  who  are  given  to 
that  affliction;  for  we  know  that  "rheumatism."  like  tuberculosis,  is 
wont  to  attack  the  parts  weakened  for  resistance.     Always  bear  in 


MASSAGE  765 

mind  this  possibility  of  ''rheumatism,"  and  during  the  convalescence 
from  sprains  forbid  alcohol  and  look  carefully  to  the  patient's  general 
condition,  especially  to  his  secretions.  That  question  of  tuberculosis 
is  an  important  one  also.  We  all  know  how  frequently  the  develop- 
ment of  a  localized  tuberculosis  may  be  traced  apparently  to  some 
trauma,  so  we  must  appreciate  the  fact  that  a  sprained  joint,  which 
remains  unsound  for  long,  especially  when  treated  by  the  old-fashioned 
immobilization,  gives  us  excellent  conditions  for  the  subsequent  de- 
velopment of  a  chronic  infection.  One  can  well  imagine  how  such  a 
joint,  ill  nourished,  anemic,  with  an  impeded  blood  ancl  lymph  current, 
partially  ankylosed,  and  associated  naturally  with  flabby,  atrophied 
muscles,  presents  an  admirable  seat  of  lodgment  for  infective  bacteria; 
so  here  we  find  further  reason  in  the  case  of  fresh  sprams  for  expediting 
a  healing. 

Another  lesion  which  furnishes  us  with  an  opportunity  for  brilliant 
results  from  massage  is  dislocation.  We  have  considered  the  value  of 
massage  in  fractures,  but  in  dislocation  its  use  is  even  more  satisfactory. 

Here  is  a  tj'pical  case — a  man  with  a  subcoracoid  dislocation  of  the 
humerus.  He  is  a  stout  man,  and  the  diag-nosis  is  not  immediately  ap- 
parent. One  does  not  readil}-  make  out  the  flattening  of  the  deltoid 
and  outward  trend  of  the  humems  away  from  the  side,  but  if  one  will 
practise  bimanual  palpation  of  the  axilla  on  both  shoulders,  one  cannot 
fail  to  estabhsh  the  diagnosis.  On  the  sound  side,  with  one  finger 
below  the  coracoid  process  and  the  other  high  in  the  axilla,  one  can 
almost  make  the  fingers  touch  through  the  pectoralis  major,  which  alone 
intervenes.  Tiy  the  same  palpation  on  the  affected  side,  and  one  finds 
that,  push  as  hard  as  he  will,  a  great  interval  still  separates  his  fingers. 
That  interval  is  occupied  by  the  head  of  the  humerus,  dislocated  under 
the  coracoid.  The  patient  is  etherized  at  once,  and  the  dislocation 
reduced.  On  the  next  day  he  returns  for  massage.  For  the  first  week 
this  will  be  given  for  twenty  minutes  daily  while  the  arm  is  supported 
motionless  in  a  sling.  The  same  method  in  general  that  we  have  seen 
employed  on  the  ankle  vaW  be  followed.  Pain  quickly  will  be  reheved, 
and  the  nutrition  of  the  parts  improved.  After  a  week,  gentle  passive 
and  active  movements  will  be  begun,  and  by  the  end  of  three  weeks 
of  such  practice  we  hope  to  have  estabhshed  a  cure. 

That  matter  of  combining  movements  with  massage  in  these  cases 
is  an  important  one.  We  shall  find,  for  instance,  in  old  shoulder  dis- 
locations which  have  been  reduced  ancl  subsequently  immobilized  for  a 
long  time,  according  to  the  ancient  practice,  wasting,  weakness,  and 
stiffness  resulting.  If,  then,  we  attempt  by  massage  to  restore  the  parts, 
we  shall  succeed  veiy  hkely  in  rendering  the  joint  supple,  but  we  shall 
not  increase  materially  the  size  and  power  of  the  muscles.  Faradism 
will  then  help,  by  causing  muscular  contractions,  but  we  can  accomplish 
the  same  thing  by  active,  resistive,  and  passive  movements.  So  remem- 
ber that  in  all  joint  injuries  massage  must  be  supplemented  by  move- 
ments, in  order  properly  to  restore  normal  function. 

There  are  numerous  other  conditions  in  which  massage  is  of  the 


766  MINOR   SURGERY— DISEASES   OF   STRUCTURE 

greatest  value/  especially  in  contractures  and  deformities  left  by  old 
injuries  or  inflammatory  processes  which  have  subsided.  In  those  cases 
patience  and  faith  are  often  required  for  a  long  time,  but  the  final  results 
usually  justify  the  treatment.  As  to  the  use  of  general  massage  after 
major  operations  and  prostrating  surgical  affections,  let  nie  say  that  I 
have  employed  it  commonly  in  such  conditions,  and  with  the  most 
gratif>-ing  results,  for  the  secretions  are  thereby  increased,  the  circula- 
tion improved,  the  appetite,  sleep,  and  mental  state  stimulated,  and  the 
convalescence,  after  the  patient's  getting- out  of  bed,  materially  and 
happily  abridged. 

1  Mechanical  massage  (Zander  treatment)  and  hydrotherapy  are  valuable  sub- 
stitutes for  manual  massage. 


CHAPTER  XXVII 

SHOCK;    BLOOD-VESSELS;    LYMPHATICS;    MUSCLES;   TEN- 
DONS; BURSAE;   SKIN 

Shock  and  Collapse 

Shock  and  collapse  are  two  ancient  terms  used  by  surgeons  to 
indicate  an  extreme  bodily  depression;  and  a  distinction  between  the 
two  conditions  has  been  asserted  from  old  time.  In  truth,  one  cannot 
but  feel  that  such  a  distinction  is  artificial,  and  that,  as  the  words  are 
commonly  employed,  shock  is  a  state  of  extreme  collapse,  or  vice 
versa,  if  you  please.  Nevertheless,  Crile  differentiates  the  two  in  a 
recent  writing,  regarding  shock  as  an  exhaustion  of  the  vasomotor 
center,  and  collapse  as  an  inhibition  of  the  vasomotor  center. 

Nearly  thirty  years  ago  William  S.  Savory,  pubhshing  in  Holmes's 
System  of  Surgery:  wrote:  ''Life  may  be  destroyed  by  certain  agents 
which  leave  no  visible  traces  of  their  operation  in  any  part  of  the  body. 
Some  forms  of  injury,  as,  for  instance,  a  blow  on  the  epigastrium,  may 
produce  sudden  death,  and  yet  the  most  searching  scrutiny  shall  fail 
to  detect  the  slightest  physical  or  chemical  change  in  any  organ  or 
structure.  Nay,  further:  life  may  be  abruptly  terminated  by  causes 
yet  more  subtle,  such  as  sudden  and  powerful  emotions  of  the  mind. 
This  kind  of  death  is  very  expressively  termed  death  from  shock."  In 
recent  years,  thanks  to  the  inquiries  of  Crile,  Howell,  Porter,  and  other 
physiologists,  we  have  learned  to  estimate  more  nearly  the  causes  of 
shock— through  investigation  upon  living  animals,  though  physiologists 
are  not  yet  in  accord.  To  quote  from  Bloodgood:  "For  practical 
purposes  shock  shall  be  considered  a  condition  of  general  depression 
produced  by  various  causes.  These  factors  act  through  the  medium 
of  afferent  nerves  upon  various  centers  in  the  spinal  cord  and  brain, 
especially  the  vasomotor  centers.  Howell,  from  his  physiologic  ex- 
periments, recognizes  a  cardiac  shock  as  well  as  a  vasomotor  shock. 
It  is  a  question  whether  the  sympathetic  ganglia  are  also  deleteriously 
influenced  by  the  various  factors  which  may  produce  shock.'' 

These  quotations  will  show  the  reader  that  the  situation  is  not  yet 
clear,  though  it  is  becoming  increasingly  evident  that  exhaustion  and 
paralysis  of  the  vasomotor  center  are  important  elements  in  shock, 
while  at  the  same  time  there  is  excellent  reason  to  suppose  that  the 
heart's  action  may  fail  through  causes  not  connected  with  the  vaso- 
motor center;  for  example,  through  irritation  or  damage  to  the  im- 
portant cervical  sympathetic  gangha.  In  this  brief  writing  one  is  not 
permitted  to  discuss  at  length  the  interesting  and  important  physiologic 

767 


768  MINOR    SURGERY — DISEASES   OF   STRUCTURE 

experiments  bearing  upon  the  subject  of  shock,  but  I  refer  the  reader 
to  the  admirable  publications  of  Crile,  Howell,  Boise,  Porter,  Blood- 
good,  Mummery,  and  Sheen. ^ 

The  most  notable  physiologic  phenomenon  in  the  condition  of 
shock  is  the  abnormally  low  blood-pressure,  though  low  blood-pressure 
may  be  found  associated  with  conditions  other  than  shock.  In  shock 
there  are  further  changes  also — an  alteration  in  respiration  and  the 
heart's  action,  a  modified  or  depressed  mental  state,  loss  of  power 
in  both  forms  of  muscles,  a  diminution  in  the  glandular  secretions,  a 
lowering  of  the  body's  temperature.  The  condition  of  the  circulation 
is  extremely  interesting,  and  we  seem  justified  in  concluding  that  a 
great  part  of  the  body's  blood  does  not  circulate  freely  through  the 
arteries,  but  accumulates  in  the  venous  trunks,  especially  in  the  abdom- 
inal veins,  so  that  the  condition  is  equivalent  to  an  internal  or  intra- 
venous hemorrhage.  The  condition  of  shock,  therefore,  simulates  closely 
the  condition  seen  in  cases  of  hemorrhage,  and  we  know  that  hemor- 
rhage is  one  of  the  important  factors  in  the  production  of  shock. 

The  leading  symptoms  of  shock  are  those  of  an  acute  anemia. 
The  blood-pressure  is  low,  often  below  50  mm.  of  mercury,  and  the 
pulse  is  usually  rapid  and  soft,  though  it  may  rarely  become  slowed. 
The  output  of  the  heart  constantly  diminishes  as  the  shock  deepens; 
the  face  becomes  blanched;  the  breathing  becomes  rapid,  sighing, 
irregular,  and  of  the  Chej^ne-Stokes  variety;  the  muscular  systems 
are  relaxed;  the  reflexes  are  diminished;  the  sphincters  are  relaxed, 
and  voluntary  muscular  action  is  abolished.  The  functions  of  diges- 
tion and  of  renal  secretion  fail  also,  while  the  skin  becomes  moist  and 
cold.  The  patient  usually  is  apathetic,  though  he  may  be  talkative 
and  excitable  rarely.  The  blanched  face  appears  shi-unken,  pinched, 
and  elongated,  while  the  chin  droops  and  languor  marks  the  expression. 
The  eyes  grow  dim  and  turn  upward  beneath  the  half-closed  lids,  but 
the  pupils  react  markedly  to  light.  Should  the  patient  die,  the  symp- 
toms persist,  becoming  constantly  more  marked  until  the  end.  In 
case  of  recovery,  however,  one  notes  first  a  slight  improvement  in 
the  rate  and  volume  of  the  pulse,  after  which  the  color  returns  gradually 
and  the  patient  begins  to  rouse  himself  and  take  notice  of  his  surround- 
ings, or  he  may  fall  into  a  quiet  and  normal  sleep. 

The  causes  which  produce  shock  are  manifold — the  most  important 
are  those  sensory  impulses  (traumatic)  which  affect  the  medullaiy 
centers;  the  next  is  hemorrhage.  Additional  causes  are  general  anes- 
thesia, long-continued  pain,  extensive  surgical  operations,  extreme 
heat  and  cold,  certain  drags,  and  strong  psychic  impressions,  while 
various  general  bodily  states  also  conduce  to  shock — anemia,  diabetes, 
nephritis,  sundry  infections,  starvation,  and  autointoxication  (Blood- 
good). 

1  George  W.  Crile,  Blood-pressure  in  Surgery;  Surgical  Shock;  Shock  and  Collapse, 
in  Keen's  Surgery',  vol.  i,  p.  922;  J.  C.  Bloodgood,  Surgical  Shock,  in  Brj^ant  and 
Buck's  American  Practice  of  Surgery,  vol.  i,  p.  463  (including  a  resume  of  Howell's 
article);  Eugene  Boise,  The  Nature  of  Shock,  Amer.  .Tour.  Obstet.,  .January,  1907; 
J.  P.  L.  Mummery,  Lancet,  April  1,  1905;   W.  Sheen,  Lancet,  June  30,  19061 


SHOCK   AND    COLLAPSE  769 

The  diagnosis  of  shock  is  sufficiently  obvious  from  the  foregoing 
description  of  the  symptoms.  For  surgeons  probably  the  most  interest- 
ing feature  in  its  causation  is  hemorrhage,  and  hemorrhage  and  shock 
frequently  are  associated.  It  is  not  possible,  however,  to  distinguish 
shock  from  hemorrhage  under  certain  conditions,  since  shock  may 
exist  without  hemorrhage,  and  hemorrhage  may  exist  without  shock. 
Hemorrhage  produces,  in  addition  to  the  general  sj-mptoms  already 
described,  certain  quite  characteristic  sj'mptoms — an  impairment  of 
vision,  irregular  tossing,  frequent  yawning,  great  thirst,  nausea,  and 
sometimes  convulsions.  The  hemoglobin  is  enormously  reduced,  while 
in  shock  it  is  unaltered.  In  hemorrhage  the  attacks  of  syncope  are 
recurrent;  in  shock  such  attacks  do  not  occur.  In  concealed  abdominal 
hemorrhage  one  may  distinguish  by  examination  evidence  of  accumu- 
lated blood  in  the  flanks,  wdiile  the  exhaustion  is  slow  and  progressive. 
Shock  is  generally  of  rapid  onset,  and  does  not  suggest  slow  exhaustion. 

The  treatment  of  shock  is  a  subject  of  constant  and  intense  interest 
to  surgeons.  It  deserves  careful  study.  Crile  is  probably  weary 
of  hearing  himself  quoted  on  this  subject,  but  in  these  da3's  his  sa}-ings 
must  fiU  the  page  of  the  writer  who  treats  of  shock.  However  the 
physiologists  dispute  as  to  the  cause  of  shock,  no  practical  surgeon 
who  has  watched  Crile's  treatment  of  shock  can  doubt  its  efficiency. 
For  the  last  seven  years  I  have  been  following  his  advice  with  satisfac- 
tion. One  endeavors:  (1)  To  prevent  further  shock;  (2)  to  support 
the  circulation;  (3)  to  secure  physiologic  rest. 

It  is  not  always  easy  to  prevent  further  shock,  but  so  far  as  he  may 
the  surgeon  must  eliminate  those  conditions  which  are  causing  the 
shock,  if  such  elimination  be  within  his  power.  He  must  check  hemor- 
rhage; he  must  reheve  pain;  he  must  remove  anxiety  and  distress. 
Even  in  those  cases  of  shock  which  have  suffered  their  misfortune 
before  the  surgeon  sees  them  he  can  assist  greatly  by  helping  to  bJunt 
the  sensibilities  and  to  quiet  apprehension.  For  this  purpose  morphin 
is  the  surgeon's  sheet-anchor.  There  can  be  no  doubt  that  mental 
strain  and  anxiety  about  his  owoi  condition  will  increase  and  prolong 
the  patient's  shock,  and  by  just  so  much  decrease  his  chances  for  re- 
coveiy. 

But  the  prevention  of  further  shock  runs  into  and  overlaps  that 
more  important  matter — the  treatment  of  present  shock,  and  this 
leads  us  to  our  second  topic,  stippoii  of  the  circulation.  That  is  a  matter 
about  which  opinions  have  differed  widely,  though,  fortunately  for 
suffering  humanity,  surgeons  are  coming  to  agreement.  We  recognize 
two  distinct  divisions  of  this  subject — two  methods  of  supporting  the 
circulation:  (1)  By  external  applications  and  posture;  (2)  by  the 
administration  of  internal  remedies.  The  first  or  mechanical  method 
is  ancient,  and  has  alw^ays  been  more  or  less  popular,  though  its  exact 
manner  of  working  only  recently  has  become  clear.  By  compressing 
the  peripheral  circulation  of  the  body  blood  is  forced  into  the  internal 
organs,  the  heart  is  stimulated  to  increased  exertion,  and  the  nervous 
system  is  encouraged  through  vasomotor  stimulation.     At  the  same 

49 


770  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

time  the  great  veins  of  tlie  abdomen  which  have  been  drinking  up 
the  patient's  blood  and  keeping  it  out  of  commission,  as  we  sa}',  are 
forced  to  disgorge  their  contents.  An  excellent  means  of  exerting 
peripheral  pressure  is  by  tight  bandaging  of  the  limbs  and  trunk  with 
broad  flannel  or  rubber  rollers.  A  still  more  effective  method — a 
method  vastly  more  effective  in  my  experience — is  the  application  of 
Crile's  pneumatic  rubber  suit,  which  can  be  inflated  in  a  minute.  It  is 
extremely  interesthig,  during  its  application,  to  watch  the  surpiising 
and  almost  instantaneous  improvement  in  the  patient's  pulse.  A 
simple  and  easy  method  of  seeking  the  same  end,  but  a  method  much 
less  effective,  is  to  throw  the  patient  into  a  modified  Trendelenburg 
position,  by  which  maneuver  the  heart's  action  is  relieved  and  the 
basal  centers  are  flooded  by  fresh  blood.  At  the  same  time  keep  the 
patient  warm  with  hot  bottles,  or  a  hot -water  bed  and  blankets. 

Saline  solutions  introduced  into  the  circulation  maj-  be  regarded 
either  as  mechanical  aids  or  as  internal  remedies,  but,  however  that 


P'ig.  468. — Crile's  pneumatic  suit  (Keen's  Surgery). 

may  be,  it  is  certain  that  the  mere  presence  of  an  increased  volume  of 
fluid  in  the  circulation  serves  for  a  short  time  to  relieve  shock,  and  is, 
most  of  all,  valuable  if  there  be  hemorrhage.  There  are  four  methods 
of  introducing  saHne  fluids:  (1)  By  intravenous  infusion — the  injec- 
tion of  the  solution  through  a  cannula  directly  into  a  vein,  choosing 
preferably  one  of  the  veins  of  the  calf  or  at  the  bend  of  the  elbow;  (2) 
by  intra-abdominal  infusion;  (3)  b}'  rectal  injections;  (4)  by  subcu- 
taneous injections.  As  Crile  remarks,  it  is  well  to  give  the  intravenous 
infusion  gradually,  since  a  great  amount  of  fluid  may  cause  acute 
dilatation  of  an  anemic  heart.  One  should  not  give  more  than  a  pint, 
as  a  inile,  but  this  amount  may  be  repeated  at  frequent  intervals.  The 
intra-abdominal  infusions  are  commonly  practised  in  the  course  of 
abdominal  operations,  the  opened  belly  being  filled  with  salt  solution 
and  sewed  up.  This  included  solution  is  absorbed  quickly.  Rectal 
injections  are  eas}^  and  comparativeh'  painless,  especially  if  given  by 
Murphy's  seeping  method  (proctoclysis),  which  I  described  in  Chapter 
VIII.     Subcutaneous  injections  (hypodermoclysis)  are  easily  given  also, 


SHOCK   AND   COLLAPSE 


771 


though  they  are  painful,  ^^'c  inject  the  fhiid  inuler  s(Hne  easily  dis- 
tensible area  of  skin  beneath  the  breasts,  the  loin,  the  thigh. 

Such  remedies  sufhce  for  most  cases  of  shock,  but  there  are  times 
when  it  will  seem  well  to  supplement  them  by  internal  medication. 
The  most  efficient  drug  at  our  command  is  adrenalin  chlorid  (1:  1000), 
15  minims  of  which  may  be  added  to  500  cc.  of  the  saline  solution; 
or  in  cases  of  extreme  urgency  we  may  inject  into  the  vein  a  continuous 
infusion  of  1 :  20,000  adrenalin  solution  at  the  rate  of  2  cc.  a  minute. 

You  shall  hear  much  talk  of  sundiy  drugs  which  clinical  experience 
seems  to  have  proved  valuable — alcohol,  ether,  strychnin,  digitaHs, 
nitroglycerin,  atropin,  etc.    -Of  these,  strychnin  and  atropin  alone  are 


Fig.  469. — Intravenous  saline  infusion.  A,  The  lower  ligature  is  tied  and  the 
upper  ligature  is  in  place  ready  for  tying.  The  valve-shaped  opening  in  the  vein 
is  shown  ready  to  receive  the  cannula.  B,  Flask  containing  the  saline  solution. 
This  flask  is  an  ordinary  wash-bottle,  the  long  glass  tube  of  which  is  connected 
to  the  infusion  cannula  and  the  short  glass  tube  to  a  rubber  bulb  with  valves.  By 
pumping  air  into  the  flask  above  the  solution  the  latter  is  forced  into  the  veins 
(Fowler). 

of  value,  and  that  only  in  appropriate  and  well-considered  cases.  We 
know  the  oft-quoted  remark  of  Mummery:  ''The  administration  of 
strychnin  in  shock  is  like  beating  a  djdng  horse;  it  may  call  forth  an 
effort  if  we  beat  hard  enough,  but  it  hastens  the  end."  However, 
there  are  frequent  cases  in  which,  strychnin  certainly  helps  to  tide  a 
patient  over  a  long,  tedious  operation.  In  the  course  of  an  extensive 
dissection,  when  the  pulse  iiins  slowl}^  or  acts  with  diminished  force, 
a  4V  or  a  ^  grain  of  strychnin  frequently  will  improve  the  situation. 
Again,  in  that  condition  which  we  call  secondary  shock — a  rising, 
feeble,  or  irregular  pulse  supervening  a  day  or  two  after  recovery  from 
the  primary  shock — small  doses  of  strychnin  are  effective — jL  grain 


772  MINOR    SURGERY — DISEASES   OF   STRUCTURE 

every  four  hours.  Atropin  is  a  useful  drng  occasionally  in  shock, 
particularly  when  the  skin  appears  moist.  As  Da  Costa  says,  quoting 
Hare,  it  is  a  sedative  to  the  vagus;  but  what  makes  it  particularly 
valuable  is  that  it  acts  upon  the  vasomotor  system,  combats  the  dilata- 
tion of  the  blood-vessels,  maintains  vascular  tone,  prevents  stagnation 
of  the  blood  in  any  vessels,  and  increases  the  amount  of  moving  blood. 

In  addition  to  the  methods  of  treatment  I  have  already  described 
there  is  the  transfusion  of  l)lood,  which  we  are  now  finding  to  be  of 
great  value  in  cases  of  shock  and  of  hemorrhage.  Transfusion,  an 
ancient  and  discredited  operation,  has  been  successful!}'  revived  in  the 
past  three  years.  Direct  transfusion  of  the  arterial  blood  of  the  donor 
into  a  vein  of  the  donee — transfusion  without  intervening  apparatus — 
is  meeting  physiologic  ideals.  Transfusion  must  usually  be  reserved 
as  a  last  resort  on  account  of  the  difficulty  of  securing  a  donor  and  the 
tediousness  of  the  operation  itself.  I  believe,  however,  that,  with  a 
wider  popular  understanding  of  its  importance,  and  with  improvements 
in  the  technic  of  the  operation,  transfusion  will  be  frequently  and  suc- 
cessfully used  in  the  future.^ 

A  brief  summary-  of  the  treatment  of  shock,  therefore,  will  include 
the  following  points:  quiet  the  pain  and  apprehension  by  a  hypoderaiic 
injection  of  morphin ;  keep  the  patient  warm ;  employ  the  Trendelenburg 
position;  bandage  the  limbs  and  abdomen,  or  apply  the  pneumatic 
suit;  use  saline  infusions;  add  adrenalin  to  the  infusion;  if  an  anes- 
thetic is  to  be  used,  employ  ether;  if  an  operation  is  imperative,  block 
the  great  nerve-tiiinks  with  intraneural  injections  of  cocain,  but,  so 
far  as  possible,  avoid  all  operations  during  shock;  endeavor  to  keep 
the  patient  comfortable  and  tranciuil;  and  in  extreme  cases  employ 
direct  transfusion  of  blood — by  far  the  most  valuable  measure  at  our 
command. 

Surgery  of  the  Blood-vessels 

Surgery  of  the  blood-vessels  is  no  novel  thing,  though  the  furor  of 
present-day  progress  might  lead  the  unsuspecting  to  assume  that  this 
is  a  new  branch  of  surgery.  The  history  of  the  subject  alone  forms 
a  fascinating  chapter,  and  one  recalls  the  fact  that  wounds  of  the 
arteries  were  treated  for  centuries  by  application  of  the  actual  cautery; 
that  Hippocrates  dealt  inteUigently  with  the  subject;  that  Galen,  in 
the  second  centurj^  a.  d.,  introduced  the  ligature  for  arteries  wounded 
in  continuity;  that  Pare  in  the  sixteenth  centur>'  applied  the  ligature 
to  arteries  severed  in  amputations;  that  the  ancients  treated  aneurysm 
by  digital  compression;  that  Antyllus,  in  the  third  century,  devised 
the  operation  of  double  ligature  and  laying  open  the  sac  for  aneurysm 
— an  operation  more  recently  modified  by  Purmann,  who  excised  the 
sac;  that  John  Hunter,  in  the  eighteenth  century,  taught  the  operation 
of  proximal  ligation  for  aneurysm,  and  finally  that  Matas,  of  Xew 
Orleans,  in  1903,  described  his  extremely  valuable  method  of  aneurys- 
mal suture. 

i  J.  G.  Mumford,  The  Blood  in  Surgerj',  Ann.  Surg.,  January,  1(110. 


THLEHITIS  773 

Wounded  arteries  and  aneurysms  do  not  furnish  the  only  material 
for  surgery  of  the  blood-vessels.  There  are  diseases  of  the  veins  and 
capillaries — inflammations,  dilatations,  and  vascular  tumors.  Let  us 
consider  shortly  some  of  the  latter  lesions,  and  then  pass  in  review  the 
more  important  advances  of  latter-day  surgery  of  the  arteries. 

Surgery  of  all  blood-vessels  is  in  some  respects  analogous  to  surgery 
of  the  intestinal  tract,  while  in  other  respects  it  differs  widely.  Both 
blood-vessels  and  intestines  have  their  three  coats  and  their  moving 
contents,  but  the  blood-vessels  are  lined  with  an  endothelium  similar 
to  the  peritoneal  and  meningeal  serosa — a  smooth,  glistening  membrane 
which,  when  irritated,  forms  ready  adhesions  and  easily  acts  to  cause 
a  coagulation  of  the  contained  blood.  But  the  contained  blood  is 
aseptic,  whereas  the  intestinal  contents  are  highly  septic.  Veins  have 
their  OM'n  peculiarities  as  distinguished  from  arteries;  they  are  thinner 
walled;  they  contain  competent  valves;  when  subject  to  infection, 
they  become  inflamed  readily,  and  this  inflammation  spreads  ciuickly 
to  their  outer  coats;  consequently  we  find  the  conditions  known  as 
phlebitis  and  periphlebitis. 

PHLEBITIS 

Phlebitis  and  periphlebitis,  the  latter  being  associated  frequently 
with  lymphangitis,  is  an  inflammation  of  the  lymphatics  along  the 
venous  walls. 

Acute  phlebitis  results  from  injuries  from  childbirth,  from  ery- 
sipelas, from  such  superficial  lesions  as  varicose  ulcers,  and  from  general 
infective  processes — especially  diphtheria,  typhoid,  pneumonia,  and 
gonorrhea.  The  phlebitis  of  typhoid  is  extremely  common.  As  a 
rule,  phlebitis  runs  a  short  and  painful  course  to  recovery,  but  in  the 
more  serious  cases  a  general  pyemia  may  supervene,  resulting  in  death. 

Chronic  phlebitis  is  a  common  affair,  and  comprehends  an  inflamma- 
tion of  a  proliferating  type,  followed  by  more  or  less  organization. 
Occasionally  phlebitis  obliterans  occurs  as  a  sequel  of  syphilis  and 
other  chronic  infections,  as  well  as  after  various  operations  upon  the 
veins. 

The  symptoms  of  acute  phlebitis  are  unmistakable  when  the  veins 
are  superficial,  but  are  obscure  when  the  veins  are  deep.  According 
to  the  situation  of  the  veins,  the  skin  may  or  may  not  become  dark 
blue  or  dusky  red  or  remain  unaffected.  The  vessel,  when  palpable,  feels 
cord-like.  Fever  comes  on  and  rises;  the  inflamed  area  is  exquisitely 
tender,  and  usually  there  is  pain.  The  blood  contained  within  the 
veins  clots,  and  if  this  clotting  be  extensive,  edema  of  the  parts  results. 
If  no  collateral  circulation  be  available,  the  result  to  the  parts  drained 
by  the  affected  veins  may  be  extremely  serious,  and  gangrene  even 
may  follow.  The  terms  phlegmasia  alba  dolens  and  milk-leg  describe 
a  painful  swelling  of  the  leg  due  to  portal,  pelvic,  and  femoral  phlebitis. 
One  cannot  readily  determine  the  more  deeply  seated  inflammations, 
but  may  infer  their  presence  from  the  fever,  the  extensive  tenderness,  the 
pain,  and  the  swelling.     One  sees,  moreover,  that  deep-seated  phlebitis 


774  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

of  important  veins  may  result  (|iii(kly  in  llie  most  frightful  calamities. 
Mesenteric  phlebitis  may  cause  mesenteric  ganjirene  and  peritonitis. 
Hemorrhoidal  jjhlebitis  nuiy  extend  to  the  higher  abtlominal  veins, 
with  fatal  result.  Umbilical  phlebitis  kills  newborn  infants,  while 
the  sinus  phlebitis  associated  with  middle-ear  disease  is  a  common 
cause  of  death  in  the  latter  ailment.  Moreover,  infected  thrombi  dis- 
lodged from  any  vein  may  be  carried  into  distant  parts  to  set  up  the 
metastatic  abscesses  of  a  general  pyemia. 

The  treatment  of  phlebitis,  therefore,  takes  on  sundry  and  quite 
diverse  phases.  The  acute  surgical  forms,  especially  phlebitis  of  the 
limbs,  generally  may  be  subdue<l  by  rest — absolute  physiologic  rest. 
Many  surgeons  employ  cold  applications  and  ichthyol  or  silver  (Crede) 
ointments.  My  own  preference  is  for  mild  creolin  poultices,  applied 
over  the  whole  limb  and  bound  gently  into  place  untler  thickly  wadded 


N. 


i.  i^\ 


X 


Fig.  470. — Varicose  vein>  of  the  leg,  extreme  type  (Massachusetts  General  Hospital). 

bandages.  The  warmth  is  extremely  agreeable,  and  the  creolin  solu- 
tion seems  to  maintain  its  heat  for  a  long  time.  One  should  change 
these  poultices  every  three  or  four  hours. 

In  all  cases  the  septic  focus  from  which  the  phlebitis  originates 
should  be  treated.  Otherwise  no  direct  interference  with  the  inflamed 
veins  can  be  effectual.  As  an  example  of  this,  one  sees  "milk-leg" 
running  an  obstinate  course  because  a  septic  infection  of  the  pelvic 
organs  has  escaped  observation.  In  the  case  of  deep  infections  causing 
thrombophlebitis  in  the  veins  of  the  pelvis,  the  neck,  or  the  head,  the 
surgeon  must  often  open  the  veins  and  turn  out  the  clots  at  the  same 
time  that  he  attacks  the  localized  underlj'ing  disease.^ 

Chronic  phlebitis  shows  its  commonest  forms  in  varicosities  of  the 
leg,  the  scrotum,  and  the  anus.     I  have  already  considered  the  two 

*  Professor  Dr.  F.  Trendelenburg,  A  Review  of  Surgical  Progress,  Trans.  Section 
on  Surgery  and  Anatomy,  Jour.  Amer.  Med.  A.ssoc.,  1906. 


rHr.KHiTis  775 

latter,  but  it  is  interesting  to  see  how,  recently,  varicosities  of  the  leg 
have  come  to  be  treated.  It  seems  probable  that  the  essential  pre- 
disposing cause  is  a  congenital  defect  in  the  vessels  or  their  iimerva- 
tion.  Inmiediate  causes  enter  in  also — occupations  involving  long 
standing,  and  probably  injuries,  constipation,  and  child-bearing. 
Gradually  the  veins  become  enlarged  and  obvious  to  sight  and  touch, 
sometimes  giving  a  sense  of  fulness  in  the  leg,  while  there  may  ensue 
edema,  pains,  a  constant  heaviness,  and  painful  cramps  at  night.  The 
skin  becomes  ill  nourished,  glossy,  eczematous,  with  a  frequently 
resulting  ulcer.  Occasionally  a  vein  ruptures,  giving  rise  to  a  sharp 
hemorrhage.  In  Chapter  XXVI,  I  discussed  at  some  length  the  simpler 
treatment  of  varicose  ulcers,  and  one  must  believe  that  sound  and  per- 
manent cure  of  these  ulcers  depends  upon  cure  of  the  varicose  veins. 

The  treatment  of  varicose  veins  in  the  leg  is  the  affair  of  the  surgeon, 
but  it  is  'often  hard  to  convince  the  sufferer  of  this  fact.  A  patient 
comes  into  a  physician's  ofhce  and  shows  a  bunch  of  varicose  veins. 
The  busy  physician  recommends  an  elastic  stocking,  and  thinks  no 
more  of  the  matter.  That  is  all  very  well,  for  if  the  patient  will  wear 
a  proper  elastic  stocking  or,  better,  a  well-made  flannel  bandage 
from  his  toes  to  above  the  knee,  he  will  get  along  comfortably  enough, 


Fig.  471. — Mayo's  vein  enucleator. 

but  he  will  find  the  wearing  irksome,  and  after  a  time  will  abandon  the 
treatment.  Then  the  varices  will  gro-w  larger,  and  the  last  state  of  that 
man  is  actually  worse  than  the  first. 

For  years  surgeons  have  endeavored,  by  extensive  dissections  and 
excisions,  radically  to  cure  these  varicosities.  They  were  working  in 
a  septic  field,  and  although  they  often  cured  the  varix,  they  submitted 
the  patient  to  a  long  and  distressing  convalescence.  Trendelenburg 
has  devised  a  useful  operation — ligation  and  section  of  the  internal 
saphenous  vein  in  the  upper  portion  of  the  thigh.  Schede's  operation 
is  popular, — the  so-called  circumcision  of  the  leg, — but  I  have  come  to 
rely  almost  entirely  upon  the  ingenious  procedure  of  C.  H.  Mayo — 
subcutaneous  enucleation :  seek  the  internal  saphenous  vein,  ligate  and 
cut  it  in  Scarpa's  triangle.  Enucleate  the  distal  severed  portion  with 
the  long-handled  ring-enucleator  pictured  here.  With  gentle  force 
pass  the  instrument  along  the  vein,  tearing  off  the  branches  for  six  or 
eight  inches.  Then  bring  out  the  end  of  the  instiniment  through  a  small 
incision.  Often  the  removal  of  this  six  or  eight  inches  is  enough  to 
establish  a  cure,  or  the  surgeon  may  repeat  the  performance,  taking  out 
several  sections  of  veins  throughout  the  length  of  the  leg.  In  the  calf 
the  enucleation  is  somew^hat  more  difficult,  and  slight  hemorrhage 
more  frequent.  For  this  one  should  elevate  the  leg,  take  out  small 
sections  of  the  vein  at  a  time,  and  tie  obstinate  bleeding  radicles.    After 


776  MIN'OH    SrUGEIlY — DISEASES   OF   STRUCTURE 

the  operation   I   di-c.s.s  the  leg  in  the  (ianigee  (h-essiiif;;  I  ilcsci'ihed  in 
Chapter  XX X' I. 

Aneurysmal  varix  is  a  dihitation  of  the  v(Mns  (hie  to  an  anastomosis 
or  connection  of  one  of  them  with  an  artery,  from  which  arterial  blood 
flows  into  antl  tlilates  them,  causing  their  pulsation.  A  variccsc  aneurysm 
is  usually  a  false  aneurysm  (such  as  formerly  occurred  commonly  after 
the  operation  of  venesection  at  the  bend  of  the  elbow),  lying  between 
a  vein  and  artery  and  communicating  with  both.  Rupture  of  a  varicose 
vein,  of  an  aneurysmal  varix,  or  of  a  varicose  aneurysm  may  occur, 
ami  obstinate  aijtl  alarming  hemorrhage  may  result.  Simple  venous 
hemorrhage,  as  from  a  ruptured  vein  in  a  varix  of  the  leg,  is  easily 
controlled.  It  suffices  usually  to  elevate  the  limb  and  apply  a  firm 
compression  dressing  for  a  f^  hours.  If  the  hemorrhage  persists, 
however,  the  surgeon  may  find  it  necessary  to  cut  down  upon  the 
damaged  vessel,  and  to  tie  it  off  above  and  below  the  damaged  point . 
Aneurysmal  varix  may  be  treated  on  the  principle  of  Matas,  as  I  sludl 
explain  later  in  this  chapter.  Varicose  aneurysm  may  be  excised  and 
the  wounded  vessels  sutured  with  through-and-through  chromic  gut 
stitches. 

ANGIOMA 

An  angioma  is  a  tumor  composed  of  blood-vessels,  and  we  group 
angiomata  as  capillary,  cavernous,  and  arterial. 

Capillary  angioma,  or   nevus,  is  that  common  form  which  I  have 
already  described  in  Chapter  XX.      A  nevus  may  be  excised,  deeply, 
scored  with  the  Paquelin   cauter}-,   treated   by   injections  of  boiling 
water,  or,  best  of  all,  by  carbon  dioxid  snow. 

Cavernous  tumors  are  similar  in  structure  to  the  corpus  caveniosum, 
for  the  vessels  become  not  merely  dilated,  but  cavernous  in  arrange- 
ment. We  see  these  tumors  in  the  tongue,  the  voluntary  muscles,  the 
liver,  the  breast,  the  larynx,  and  under  the  peritoneum.  They  ma}' 
also  be  treated  by  excision,  by  boiling  water  injections,  b}-  electroh'sis, 
or  by  carbon  dioxid  snow. 

Arterial  or  plexiform  angiornata  are  also  called  cirsoid  aneurysms. 
We  treat  them  by  careful  and  wide  dissections,  often  repeated,  until 
the  whole  mass  of  affected  vessels  has  been  removed. 


The  Arteries 

Surgery  of  the  arteries  finds  expression  in  three  directions — in 
ligation,  in  the  treatment  of  aneurysm,  and  in  the  suture  of  arteries — 
the  last  a  new  and  increasingly  important  topic. 

LIGATION  OF  ARTERIES 

In  former  times,  when  sepsis  raged,  when  secondary  hemorrhage 
was  common,  and  hemostatic  instruments  were  crude,  the  ligation  of 
arteries  was  taught  as  one  of  the  most  important  branches  of  surgical 


LIGATION    OF   ARTERIES 


777 


handicraft.  To-day  it  is  rare  for  the  operating  surgeon  to  seek  and 
tie  an  artery  in  continuity,  except  for  the  treatment  of  aneurysm.  He 
may  occasionally  expose  and  control  temporarily  a  vessel  with  Crile's 
clamp  in  order  to  render  bloodless  a  distant  field  of  operation. 

Text-books  of  operative  surgery  deal  extensively  with  the  ligation 
of  arteries.  I  shall  content  myself  with  describing  the  method  of 
approaching  and  securing  a  few  of  the  more  important  vessels. 


Fig.  472. — Ligation  of  arteries  in  neck,  chest,  and  shoulder:  1,  Hypoglossal 
nerve;  2,  facial  artery;  3,  external  carotid  artery;  4,  great  cornu  of  hyoid;  5,  sub- 
maxillary gland;  6,  digastric  and  stylohyoid;  7,  external  jugular  vein;  8,  stemo- 
mastoid  muscle;  9,  descendens  noni  nerve;  10,  omohyoid;  11,  sternomastoid 
muscle;  12,  vagus  and  recurrent  laryngeal  nerves;  13,  internal  jugular  vein;  14, 
thyroid  gland;  15,  sternohyoid  muscle;  16,  anterior  jugular  vein;  17,  clavicular 
portion  of  pectoralis  major;  18,  deltoid  muscle;  19,  median  nerve;  20,  axillary  artery, 
first  part;  21,  pectoralis  major  muscle;  22,  internal  intercostal  muscle;  23,  pleura; 
24,  internal  mammary  artery;  25,  edge  of  sternum;  26,  pectoralis  major  muscle; 
27,  external  anterior  thoracic  ner\'e;   28,  axillary  vein. 


The  innominate  artery  was  tied  first  on  the  living  in  1818  by  the 
distinguished  New  York  surgeon,  Valentine  Mott;  his  patient  died  a 
month  later.  In  1864  A.  W.  Smyth,  of  New  Orleans,  tied  the  innom- 
inate, and  his  patient  lived.  Up  to  1905  the  innominate  had  been 
tied  some  thirty-five  or  forty  times,  according  to  Roswell  Park.  An 
excellent  account  of  ligation  of  the  innominate,  with  a  complete  bib- 


778 


MINOR    SURGERY — DISEASES   OF    STRUCTURE 


liogruphy,   is  Herbert   L.  liurreU's/  who    performed    the  operation  in 
1895.     His  patient  died  in  the  fourth  month. 

The  approved  steps  of  the  operation  are  as  follows:  Make  the  incision 
along  the  anterior  border  of  the  stemomastoid  muscle,  down  to  the 
clavicle,  and  then  along  the  inner  third  of  the  bone,  thus  forming  a 
flap.  Divide  the  sternal  and  clavicular  attachments  of  the  muscles, 
and  free  the  upper  border  of  the  sternum,  taking  pains  to  avoid  the 
anterior  jugular  vein  and  the  pneumogastric  and  recurrent  laryngeal 
nerves.     Burroll  cvit  away  the  end  of  the  sternum.     Find  the  conmion 


Fig.  473. — Certain  nerves,  vessels,  and  muscles  of  neck  and  shoulder  (redrawn 
from  Kocher):  1,  Great  auricular  nerve;  2,  spinal  accessory  nerve;  3,  external 
jugular  vein;  4,  internal  jugular  vein;  5,  hypoglossal  nen-e;  6,  descendens  noni 
nerve;  7,  stemomastoid  muscle;  8,  external  carotid  artery;  9,  superior  larj'ngeal 
nerve;  10,  superior  thyroid  artery;  11,  greater  comu  of  hyoid;  12,  transversalis 
colli  artery:  13,  scalenus  medius  muscle;  14,  trapeziiis;  15,  claAncular  superficial 
cervical  nerve;  16,  first  rib;  17,  brachial  plexus;  18,  omohyoid;  19,  platyt^ma; 
20,  external  jugular  vein;  21,  phrenic  nerve;  22,  scalenus  anterior  muscle;  23,  stemo- 
mastoid muscle;  24,  subclavian  artery. 

carotid,  trace  it  down  to  the  innominate,  and  with  careful  manipulation 
throw  a  silk  or  linen  ligature  about  the  innominate  and  tighten  slowly 
the  thread.  If  one  is  tying  the  innominate  for  subclavian  aneurysm, 
he  should  tie  the  common  carotid  at  the  same  time.  Park  suggests 
that,  as  an  additional  step  in  the  technic.  one  might  well  follow  Crile's 
method  in  the  removal  of  goiters— placing  the  patient  in  a  semi-upright 
position  and  applying  the  pneumatic  suit.  As  the  innominate  is  being 
tied,  lower  the  patient  and  lessen  the  pneumatic  pressure. 

1  H.  L.  Burrell,  Trans.  Amer.  Surg.  Assoc,  1895. 


LIGATION   OF   ARTERIES  779 

These  wounds  should  be  drained,  the  arm  warmly  wrapped  and 
kept  at  rest,  and  pain  relieved  by  frequent  doses  of  morphin. 

The  common  carotid  is  easily  reached  and  tied  by  splitting  down 
through  the  sternomastoid  muscle  at  the  level  of  the  cricoid  cartilage, 
turning  aside  the  deep  jugular,  and  separating  carefully  the  artery 
from  its  sheath  before  applying  the  ligature. 

The  external  and  internal  carotids  are  readily  found  also  by 
carrying  the  cut  a  little  higher,  seeking  the  anterior  border  of  the  sterno- 
mastoid, and  finding  the  origins  of  the  two  arteries  at  the  bifurcation 
of  the  common  carotid.  The  pulsation  of  all  these  arteries  may  be 
detected  readily  by  the  exploring  finger. 


Fig.  474. — Ligation  of  axillary  artery  (after  Park). 

Tie  the  lingual  artery  by  turning  up  a  crescentic  flap  beneath  the 
jaw,  exposing  the  digastric  triangle,  and  finding  the  artery  immediately 
above  the  digastric  muscle. 

Tie  the  facial  artery  on  the  edge  of  the  jaw,  where  it  is  felt  to 
beat  at  a  point  half-way  between  the  symphysis  and  the  angle  of  the 
jaw. 

It  is  needless  to  detail  here  directions  for  finding  the  various  other 
small  arteries  of  the  head  and  neck.  The  curious  student  may  consult 
books  on  surgical  anatomy  or  operative  surgery. 

The  axillary  artery  is  divided  into  three  portions  by  the  pectoralis 
minor  muscle,  and  is  usually  tied  in  its  third  portion.  Approach  it 
through  an  incision  in  the  midaxilla;  expose  and  divide  the  deep  fascia; 
draw  outward  the  coracobrachialis  muscle  and  the  musculocutaneous 
nerve,  and  detect  with  the  finger  the  pulsating  artery. 


780 


MINOR    SUIUJERY-    DISEASES    OF    STHLTTURE 


Find  the  brachial  artery  in  the  middle  of  the  arm  on  the  inner 
border  of  the  biceps,  taking;'  puins  to  avoid  tiie  median  nerve. 

Find  the  radial  artery,  high  in  the  forearm,  by  opening  between 
the  supinator  longus  and  the  pronator  radii  teres.  The  artery  lies 
beneath  the  supinator  on  a  direct  line  with  the  brachial.  In  the  middle 
of  the  forearm  the  radial  lies  along  the  border  of  the  supinator  longus, 
and  it  maintains  the  same  relation  at  the  wrist. 

Sir  Astley  Cooper  performed  the  pioneer  ligation  of  the  abdominal 
aorta  in   IS  17,  approaching  the  vessel  through  the  linea  alba.     His 

patient  lived  forty  hours.  A  few  bokl 
men  have  followed  Cooper's  example. 
In  America.  Hunter  McGuire,  of  Rich- 
mond, performed  the  oj^eration  in  1S68. 
Experience  seems  to  prove  useless  the 
daring  experiment.  All  the  patients 
have  died.  Ligation  of  the  aorta  has 
always  been  done  for  aneurysm,  and  it 
may  be  that  the  occlusion  bands  of 
Halsted,  the  artery  suture  of  Matas, 
or  electrolysis  shall  successfidly  accom- 
plish that  in  which  ligation  has  failed. 
It  is  not  difficult  to  reach  the  aorta  by 
an  extraperitoneal  route,  opening  down 
upon  the  peritoneum  along  the  crest  of 
the  ilium,  and  turning  back  the  peri- 
toneum with  its  contained  viscera. 
This  is  an  easy  method,  as  one  elimi- 
nates thus  the  difficult  packing  off  of 
the  intestines  required  when  opening 
in  the  median  line.  By  the  extra- 
peritoneal route  a  wide  and  deep  field 
is  exposed,  in  which  one  finds  readily 
both  the  aorta  and  the  common  iliac. 
To  tie  the  external  iliac,  cut  down 
parallel  to,  and  just  above  Poupart's 
ligament,  turn  back  the  peritoneum, 
and  find  the  artery  at  the  midpoint 
between  the  pelvic  s}'mphysis  and  the 
anterior  superior  spine  of  the  ilium. 

The  line  of  the  femoral  artery  runs 
from  the  midpoint  of  Poupart's  liga- 
ment to  the  internal  tuberosity  of  the 
femur  at  the  knee.  We  tie  it  either  high  at  the  apex  of  Scarpa's 
triangle,  or  in  Hunter's  canal  beneath  the  long  saphenous  vein,  near 
the  outer  edge  of  the  sartorius  muscle,  between  the  adductor  magnus 
and  the  vastus  intemus  muscles. 

The  posterior  tibial  artery  lies  in  a  line  between  the  middle  of  the 
popliteal  space  and  a  point  midway  between  the  internal  malleolus 


Fig.  475. 


-LifTation  of  brachial 
artery. 


LIGATION    OF   ARTERIES 


781 


Fig.  476. — Approach  to  abdominal  aorta  and  ((unmon  iliac  artery. 


Fig.  477. — Ligation  of  external  iliac  arterj', 


782 


MIXOK    SUIUIEUY  —  DISEASES    OF    STRl.CTUKE 


and  the  tip  of  the  heel.  Iligli  in  tlio  calf  one  seeks  the  artery  by  find- 
ing the  tendon  of  the  pkmttiris  between  the  two  heads  of  the  gastroc- 
nemius, following  it  down  and  feeling  the  artery  Ijeneath  the  soleus. 
Lower  down  one  readily  finds  the  artery  lying  in  its  proper  line,  on  the 
flexor  longus  digitoi'uin.  and  to  the  inner  side  of  its  own  accompanying 
nerve. 

The  anterior  tibial   artery  lies  on  the  front  of  the  leg,  in  a  line 
drawn  from  a  point  between  the  head  of  the  fibula  and  the  outer  tuberos- 


flp 


Fig.  47:>. — Ligation  of  femoral  arten' 


Fip;.   479. — Ligation    of    ])ost('rior    tibial 
artt'iy. 


ity  of  the  tibia,  to  the  midtUe  front  of  the  ankle-joint.  One  exposes  it 
easily  in  this  line,  and  finds  it  lying  between  the  tibialis  anticus  and 
the  common  extensor  of  the  toes. 

In  any  case,  when  seeking  the  arteries  of  the  leg,  one  should  flex 
the  limb  so  as  to  render  dissection  the  least  difficult,  and  to  bring  the 
vessels  into  their  easy  normal  relations. 


ANEniYSM 


783 


After  tying  iiii  Jirtory  in  one  of  the  extremities,  close  the  wound 
snugly  with  stitches,  elevate  the  linih,  and  strive  to  e([ualize  its  circula- 
tion by  well-padded  bandages  applied  ,,  .» 
throughout  its  whole  length. 


ANEURYSM 

Bryant  ^  defines  aneurysm  as  "  either 
a  sacculated  tumor  containing  blood 
communicating  with  the  canal  of  an 
artery  and  formed  more  or  less  from 
its  walls,  or  a  fusiform  dilatation  of 
an  artery."  That  is  a-  sufficiently 
satisfactory  definition,  though  every 
writer  has  his  own  fanc}'.  There  are 
true  aneurysms  and  false  aneurysms 
— when  the  blood  is  contained  within 
all  three  arterial  coats,  or  when  one 
or  more  coats  are  ruptured  and  a  sort 
of  hernia  of  the  remaining  coats 
occurs.  Again,  aneurysms  are  fusi- 
form, are  sacculated,  are  dissecting, 
as  the  cuts  taken  from  Holmes  show 
graphically.  There  are  arteriovenous 
aneurysms,  in  which  the  lumen  of  an 
artery  having  become  connected  with 
that  of  a  vein,  the  heart's  action 
causes  the  walls  of  the  latter  to  pul- 
sate and  dilate.  This  form  is  some- 
times called  an  aneurysmal  varix. 
And  there  is  the  varicose  aneurysm 
also. 

Few  studies  in  surgical  history  are 
more  fascinating  than  this  of  aneurysm, 
and  great  writers  through  all  time  seem 
to  have  dwelt  upon  it  as  upon  a  matter 
concerning  that  noblest  of  our  physical 
functions,  the  circulation  of  the  blood, 
until  near  the  end  of  the  nineteenth  century  appears  to  have  conceived 
of  any  cure  for  aneurysm  save  that  involved  in  the  extermination  of 
the  affected  artery.  It  remained  for  an  American  surgeon,  Matas,  first 
experimenting  in  1888,  to  show  that  the  damaged  vessel  ma}'  be  re- 
paired, that  the  aneurysm  may  be  eliminated  directly  by  mechanical 
means,  and  that  the  offending  artery  may  be  reestablished  in  normal 
function  through  direct  circulation  past  the  site  of  the  obliterated 
disease. 

The  causes  of  aneurysm  are  either  a  previous  disease  of  the  vessel 
1  Thomas  Biyant,  Practice  of  Surgery,  edition  of  1885. 


Fig.  480. — Ligation  of  anterior  tibial 
arteiy  (peroneal). 

Yet  no  writer  from  Galen's  day 


784 


MINOR    SURGERY — DISEASES    OF    STRUCTURE 


or  an  injury  by  whicli  the  arterial  coats  are  Aveakened  or  ruptured. 
Syphilis  or  some  toxemia  leads  to  aneurysm  through  an  endarteritis 
or  its  continuation  into  atheroma.  In  this  way  an  atheromatous  ulcer 
may  cause  a  breaking  down  of  the  intima  of  the  vessel  and  the  escape 
of  blood  between  its  coats — dissecting  aneurysm.  Or  all  the  coats  of 
the  vessel  may  stretch;  or  an  actual  traumatic  tearing  of  the  vessel  may 


Fig.  481. — Aneurysmal  varix  (Bryant). 

allow  blood  to  escape  into  the  surrounding  tissues,  where  it  becomes  fully 
encapsulated — a  form  of  false  aneurysm.  Internal  aneurysms — those 
within  the  cavities  of  the  body — seldom  come  within  the  surgeon's  pur- 
view, while  external  aneurysms — in  the  arteries  of  the  limbs — properly 
come  to  him  for  treatment. 

The  progress  of  the  disease  may  be  uninterrupted  up  to  the  point 
of  rupture,  or  there  may  l:tc  spontaneous  checking  through  coagulation 


Fig.  482. — True  aneu- 
rj'sm;  the  sac  formed  Ijy 
all  the  coats  (Holmes). 


Fig.  483. — False  aneu- 
rysm;  the  sac  formed  hy 
the  outer  coat  only 
(Holmes). 


Fig.      484. — Dissecting 
aneur\'sm  (Holmes). 


and  the  formation  of  a  clot  within  the  aneurysm.  This  clotting  of  the 
blood  takes  place  in  thin  laj'ers  along  the  walls  of  the  aneurysm,  so  that 
on  dissection  of  a  large  aneurysmal  clot  one  finds  a  lamellated  appear- 
ance. Through  the  formation  and  absorption  of  these  layers  the 
aneurysmal  wall  is  streng1:hened  or  weakened  and  the  final  catastrophe 
is  often  more  or  less  postponed.     But  a  growing  aneurysm  always 


ANKURYSM  785 

encroaches  upon  surroundino;  structures.  It  pushes  aside  moval^le 
organs;   it  causes  atrophy  of  lixed  soft  parts;  it  erodes  bone. 

Aneurysms  may  be  single  or  multiple;  large  or  small;  and  no  artery 
of  the  body  is  exempt  from  the  disease,  but  the  aneurysms  of  the  large 
vessels  of  the  extremities  are  those  especially  which  interest  the  surgeon. 

The  symptoms  of  aneurysm  are  manifold  and  depend  largely  upon 
the  situation  of  the  disease.  The  patient  complains  of  discomfort, 
such  as  that  caused  by  a  rapidly  growing  encapsulated  tumor,  pain, 
indefinite  aches,  a  sense  of  weight  and  fulness,  general  debility,  lassitude, 
sometimes  emaciation.  He  may  notice  the  swelling  if  it  is  near  the 
surface,  and  he  may  be  distressed  by  the  constant  throbbing.     The 


I  j^ 


Fig.  48.'). — Aneurysm  of  innominate  artery  (Massachusetts  General  Hospital). 

surgeon  makes  his  diag-nosis  of  internal  aneurysm  with  some  difficulty. 
He  may  distinguish  an  obscure  tumor  by  its  dulness  or  flatness  on  per- 
cussion. He  may  hear  a  characteristic  bruit,  synchronous  with  the 
cardiac  systole.  He  may  feel  the  expansile  pulsation.  If  the  aneu- 
rysm is  superficial,  the  examiner  should  make  his  diagnosis  without 
great  difficulty— from  the  history,  the  presence  of  a  tumor  with  its 
characteristic  expansile  pulsation,  its  bruit,  and  the  fact  that  it  can 
be  emptied  by  pressure.  Moreover,  it  is  located  in  the  course  of  one  of 
the  arterial  trunks.  Often  there  is  edema  of  the  parts  with  venous 
congestion,  so  extreme  as  to  threaten  or  actually  to  cause  gangrene. 
Should  the  other  methods  of  examination  fail  to  determine  the  aneu- 

50 


786 


MINOR    SURGERY — DISEASES    OF    STRUCTURE 


tysm,  especially  if  it  be  internal,  the  x-ray  picture  often  gives  striking 
and  conclusive  evidence. 

The  treatment  of  aneurysm  has,  until  recent  years,  been  dependent 
upon  two  principles  which  may  be  regarded  as  branches  of  one — (1) 
An  endeavor  to  assist  nature  by  favoring  the  fomiation  of  clots,  and 
(2)  the  actual  shutting  off  of  the  affected  artery  by  ligature,  thus  caus- 
ing stagnation  and  clot  fonnation.  The  first  method  must  still  be 
considered,  especially  when  one  is  dealing  with  large  internal  aneurj'sms. 
In  order  to  favor  clotting  surgeons  have  prescribed  absolute  rest  in  bed, 
a  starvation  diet,  and  cardiac  sedatives;  to  this  have  been  added,  of 
recent  years,  more  active  intervention  by  the  use  of  gelatin  injections 
into  the  circulation,  and  the  introdution  of  wire,  with  or  without  the 
use  of  electricity,  into  the  aneurysmal  sac.  The  last  method  has  been 
moderately  successful.    Hobart  A.  Hare,^  of  Philadelphia,  thus  treated  1 1 


ij 


N^ 


?ig.  486. — A,  Operation  of  Antyllus;    B,    operation  of   Hunter;   C,  operation   of 

Anel. 


cases,  in  all  of  which  there  was  undoubted  symptomatic  relief,  though 
permanent  cures  were  not  established.  The  method  consists  in  passing 
into  the  aneurysm  a  considerable  length  (many  feet)  of  a  fine  silver 
wire,  and  submitting  it  to  electrolj'sis  for  twenty  minutes  or  half  an 
hour.  ■  Clotting  promptly  occurs  and  the  wire  is  left  in  situ. 

E.  Lancereaux  ^  has  succeeded  in  arresting  the  progress  of  internal 
aneurysm  by  injections  of  gelatin  serum,  which  he  asserts  t  be  harm- 
less if  the  serum  is  aseptic.  The  essential  weakness  of  the  lot-favor- 
ing methods,  when  applied  to  the  great  terminal  arteries  that  they 
may  lead  to  complete  obliteration  of  the  vessel — an  event  t  be  avoided. 
Per  contra,  should  a  channel  for  the  blood-current  remain,  there  is  the 
inevitable  danger  of  return  of  the  disease. 

Halsted's  metallic  bands  give  promise  of  usefidness.     His  work  is 


1  Therap.  Gazette,  July  15,  1905. 


-  Gaz.  des  Hop. 


ANEURYSM 


787 


experimental  as  yet.  It  consists  in  binding  the  affected  artery  with  a 
thin,  broad  metallic  circlet  which  shall  limit,  but  not  cut  off,  the  blood- 
stream, and  shall  favor  coagulation  in  the  aneurysm  beyond  the  band. 
Open  division  of  aneurysm  is  a  method  of  treatment  running  back 
into  antiquity.  It  is  known  as  the  method  of  Antyllus,  a  surgeon  of  the 
third  century  a.  d.,  and  has  been  practised  by  many  surgeons  in 
modern  times.  It  is  a  common-sense  method,  and  in  these  days  of 
asepsis  shows  a  comparativel}^  Ioav  mortality.  The  technic  is  simple, 
but  is  applicable  to  external  aneurysms  only.  After  controlling  the  ves- 
sel with  a  tourniquet  the  surgeon  cuts  down  upon  the  tumor,  opens 
it,  turns  out  the  clots,  and  secures  by  ligature  its  afferent  and  efferent 
vessels  above  and  below  the  aneurysm.  Some  operators  have  seemed 
to  think  that,  in  its  essential  principles,  this  operation  does  not  differ 
greatly  from  that  of  Matas.     That  conception  is  erroneous. 


Fig.  487. — D,  Operation  of  Brasdor;  E,  operation  of  Wardrop. 

Extirpation  of  the  sac  is  a  modification  of  the  AntyUian  method, 
and  has  been  favored  by  many  modern  surgeons.  Undoubtedly,  it  is  an 
improvement  upon  the  Antyllian  method,  but  it  has  its  disadvantages, 
as  I  shall  show. 

Far  the  most  popular  operation  until  recent  years  has  been  that  of 
Hunter — proximal  ligation  of  the  artery  at  a  distance  above  the 
aneurysm  but  below  the  large  anastomosing  vessels.  John  Hunter's 
claspi"  tion,  performed  in  1786,  was  done  for  popliteal  aneurysm. 

'^'  ■'moral  in  Hunter's  canal  below  the  profunda  and  secured 

,ult. 

The  disadvantages  and  dangers  of  the  Antyllian  and  Hunterian 
operations  may  not  offset  the  advantages,  but  it  is  worth  our  while 
briefly  to  consider  this  question.  The  original  operation  of  Antyllus 
has  the  advantage  of  occluding  the  artery  close  above  the  aneurysm 
and  close  below  it,  so  that  the  higher  anastomotic  branches  of  the  main 


788 


MINOR   SURGERY — DISEASES   OF   STRUCTURE 


artery  are  not  disturbed,  and  arc  left  to  carry  blood  to  the  distant 
parts  of  the  affected  limb.     At  the  same  time,  liowe\-er,  as  Matas  has 


Fig.  488. — Operation  to  restore  current  in  saccular  aneurv'sm,  first  stage:  Plac- 
ing of  interrupted  sutures  through  borders  of  arterial  opening  into  aneurysm, 
leaving  channel  of  vessel  intact  (Matas). 

sho-wn,  this  operation  does  not  control  supernumerary  feeders  to  the 
aneurysm.     These  feeders  ma^-  dilate  and  bleed  into  the  sac  after  the 


Fig.  489. — Operation  to  restore  current  in  saccular  aneurj'sm,  second  stage: 
The  interrupted  sutures  through  the  borders  of  the  arterial  opening  have  been  tied. 
A  second  tier  of  interrupted  sutures  overlying  and  outlying  tlie  first  is  being  placed 
through  the  inner  coats  of  the  aneurj'smal  sac,  wliich,  upon  being  tied,  will  bury 
the  first  tier  and  ridge  up  the  floor  of  the  aneurysm  in  the  median  line  (Matas). 

operation,  for  we  must  remember  that  an  essential  step  in  the  operation 
of  Antyllus  consists  in  opening  and  clearing  out  the  sac.     In  recent 


ANEURYSM 


789 


years  surgeons  have  substituted  excision  of  the  sac  for  opening  it — an 
interesting  advance  in  treatment;  but  excision  of  the  sac  involves 
the  removal  often  of  many  small  vessels,  and  sometimes  of  nerves 
and  other  structures  embedded  in  the  aneurysm's  wall.  Even  so,  the 
operation  of  Antyllus,  modified  by  excision,  has  shown  admirable 
results  during  the  aseptic  period— the  operative  mortality  being  zero, 
and  subsequent  gangrene  being  recorded  in  but  2.77  per  cent,  of  the 
cases.  One  concludes  then  that  extirpation  constitutes  an  extremely 
valuable  operation.  The  Hunterian  operation  seems  easy  and  little 
formidable  at  a  first  glance.     It  consists  in  tying  the  affected  artery 


Fig.  490. — Aneurysmorrhaphy :  Op- 
eration to  restore  current  in  fusiform 
aneurysm.  Suturing  borders  of  open- 
ing and  of  connecting  groove  over  a 
temporary  rubber  tube,  the  ends  of 
which  are  seen  projecting  into  the 
lumen  of  the  vessels  at  either  end. 
The  interrupted  form  of  suture  is  here 
shown  (modified  from  Matas) . 


Fig.  491. — Aneurysmorrhaphy:  Op- 
eration to  restore  current  in  fusiform 
aneurysm.  The  interrupted  sutures 
placed  in  the  preceding  figure  have 
been  tied  at  the  two  ends,  while  those 
in  the  center  are  being  held  apart  dur- 
ing the  withdrawal  of  the  rubber  tube, 
after  wliich  these  also  are  tied.  Some 
of  the  second  tier  of  sutures  are  shown 
in  place,  ready  to  be  tied  (modified 
from  Matas). 


well  above  the  aneurysm,  but  below  the  largest  anastomotic  branch 
of  the  vessel  affected  (for  example,  in  the  case  of  popliteal  aneurysm 
one  would  tie  the  femoral  artery  a  little  below  the  origin  of  the  pro- 
funda) .  Hunter's  operation  has  the  advantage  of  shutting  off  effect- 
ively the  blood-supply  of  the  aneurysm  in  nearly  all  cases,  but  it  has 
the  disadvantage  of  interfering  seriously  with  the  circulation  of  the 
limb,  so  that  even  in  recent  years  it  has  been  followed  by  an  operative 
mortality  of  8.32  per  cent. 

Many  surgeons  still  advocate  digital  compression  of  the  artery  above 
the  aneurysm,  with  the  purpose  of  favoring  clot-formation  in  the  sac. 
I  cannot  recommend  this  procedure.     It  is  extremely  uncertain,  tedi- 


790 


MINOR   SURGERY — DISEASES   OF   STRUCTURE 


ous,  for  it   involves   often  several  days   of  treatment,  painful,  and  is 
occasionally  followed  by  gangrene. 

The  foregoing  statements  represent  the  experience  and  views  of 
surgeons  up  to  the  year  1902,  when  Rudolph  Matas  described  his  method 
of  aneiiri/stnorrhaphfj}  At  that  time  numerous  investigators,  both  in 
Europe  and  America,  had  demonstrated  the  possibility  of  operating 
upon  blood-vessels  by  various  methods  of  suture,  so  that  the  fact  was 
well  established  that  wounded  vessels  heal  readily,  and  that  the  intima 
of  vessels,  like  the  peritoneum  and  serosa  elsewhere,  glues  quickly  to 

itself.  Serosa  to  serosa  and  intima  to  in- 
tima are  axioms.  Acting  upon  this  ac- 
knowledged fact,  Matas  showed  in  a 
remarkable  series  of  cases  that  it  is  pos- 
sible to  open  an  aneurysmal  sac  and  to 
sew  up  the  mokiiths  of  the  arteries  open- 
ing into  it.  J?.romptly  intima  adheres  to 
intima,  so  that  all  the  vessels  concerned 
are  obliterated. .  But  Matas  went  further, 
and  demonstrated,  by  careful  studies, 
that  the  preservation  of  the  sac  itself  is 
an  important  element  of  success  in  these 
cases.  He  retains  the  sac,  therefore,  in- 
folding and  crumpling  it  as  the  illustra- 
tions show;  for  the  sac  is  vascular,  and 
its  contained  arterioles  are  of  service  in 
preventing  local  necrosis.  The  principle 
of  Matas  is  applicable  to  all  forms  of 
aneurysm  when  the  aneurysm  is  acces- 
sible to  operative  manipulations.  The 
sacculated  aneurysm,  with  its  single  ori- 
fice, may  be  treated  readily  without  in- 
terference with  the  main  arterial  trunk. 
The  t3^pical  false  aneurysm  ma}'  be 
cleaned  out  and  the  damaged  artery  re- 
paired; while  in  the  case  of  fusiform 
aneurysm,  all  the  arterial  openings  may 
be  closed  without  subsequent  ill  effects 
so  far  as  present  knowledge  teaches.  In 
a  few  selected  cases  of  fusiform  aneurysm 
it  is  possible  to  restore  the  arterial  trunk 
by  stitching  up  the  sac  so  as  to  leave  behind  a  channel.  Progressive 
surgeons  with  enthusiasm  have  followed  the  lead  of  Matas.  More  than 
80  cases  of  his  operation  have  been  reported  with  resulting  cure  of 
the  aneur^^sm,  preservation  of  the  limb,  and  avoidance  of  gangrene 
in  nearly  all  the  cases.     We  are  justified  in  asserting,  therefore,  that 

1  Ann.  Surg.,  February,  1903;  soo  also  Medical  News,  Philadelphia,  October  27, 
1888,  in  which  Matas  described  his  first  successful  case,  though  he  did  not  at  that 
time  propose  suture  as  Ihe  routine  treatment  of  aneurj'sm. 


Pig.  492. — Aneurysmorrhaphy : 
Final  stage  of  operation.  The 
walls  of  the  aneurysm  sac  and 
the  integuments  are  sutured  to 
the  floor  of  the  sac  over  gauze 
rollers,  thus  firmly  approximat- 
ing the  former  to  the  latter  ( Bick- 
ham,  modified  from  Matas). 


ANEURYSM 


791 


Matas'  operation  is  the  operation  of  choice  whenever  its  performance  is 
possible. 

The  standard  text-books  discuss  sundry  other  methods  of  ligation 
of  arteries  for  aneurysm — Anel's  method,  which  consists  in  placing  a 
single  ligature  immediately  above  the  aneuiysm;  Brasdor's  method, 
the  ligation  of  the  artery  immediately  below  the  sac;  and  Warch'op's 
method,  the  ligation  of  the  highest  main  branch  given  off  below  the 
sac.  The  last  two  methods  may  be  our  only  resort  in  the  case  of  certain 
aneurysms  deeply  placed  and  difficult  of  access — innominate  aneurysm, 
for  example,  for  which  one  might  be  forced  to  tie  the  subclavian,  the 
common  carotid,  or  both.  When  all  is  said,  however,  our  operation  of 
choice  must  be  by  Matas's  method  or  by  excision. 


Fig.  493. 


Fig.  494. 


Fig.  493. — Aneurysmorrhaphy:  Cross-section  of  the  parts  involved  in  the  opera- 
tion where  the  current  is  restored,  together  with  the  complete  obliteration  of  the 
sac  of  the  aneurysm:  A,  Integuments;  B,  aneurysmal  sac;  C,  walls  of  blood-channel; 
D,  first  tier  of  sutures,  approximating  walls  of  blood-channel;  E,  second  tier  of 
sutures,  approximating  floor  of  sac  over  first  tier;  F,  F,  sutures  through  walls  and 
into  floor  of  aneurysm,  approximating  former  to  latter;  G,  suture  through  margin 
of  integuments  and  into  floor  of  sac,  over  second  tier;  H,  restored  blood-channel 
(modified  from  Matas). 

Fig.  494. — Aneurysmorrhaphy:  Cross-section  of  the  parts  involved  in  the  opera- 
tion where  the  blood-channel,  together  with  the  aneurysmal  sac,  are  completely 
obliterated.  The  figures  are  the  same  as  in  Fig.  493,  except  that  H  here  repre- 
sents the  obliterated  blood-channel  (Bickham,  modified  from  Matas). 


Aneurysmal  varix,  if  treated  at  all,  may  be  cured  by  applying  the 
principle  of  Matas — laying  open  the  distended  vein  and  suturing  from 
within  the  anastomotic  opening.^ 

In  any  case  of  operation  for  any  form  of  aneurysm  the  surgeon 
should  see  to  it  that  the  patient  has  careful  after-treatment.  The 
wound  should  be  dressed  with  abundant,  elastic  compression  dressings; 
the  involved  limb  should  be  bandaged  throughout  its  entire  length; 
should  be  well  supported,  and  should  be  kept  at  rest  for  two  or  three 
weeks  or  until  satisfactory  collateral  anastomosis  has  been  fully  estab- 
lished. If  all  goes  well,  the  patient  should  be  able  to  get  about  and 
use  the  arm  or  leg  freely  at  the  end  of  a  month. 

1  Warren  S.  Bickham,  Ann.  Surg.,  1904,  vol.  xxxix,  p.  767. 


792  MINOR   SURGERY— DISEASES   OF   STRUCTURE 


SUTURE   OF  THE   BLOOD-VESSELS 

Suture  of  the  Ijlood-vessels  is  a  subject  which  suggests  itself  at  once 
in  connection  with  .Matas's  treatment  of  aneurysm.  I  have  aheady 
dealt  with  suture  of  the  heart  in  Chapter  X\II1,  but  recently  a  new 
branch  of  surgery  has  been  developed  in  the  suture  of  the  blood-vessels 
(angiorrhaphy).'  One  may  not  dwell  profitably  in  this  place  upon  the 
great  literature  which  has  grown  up  about  the  subject.  Suffice  it  to  say 
that  l)eginning  with  Lambert's  first  pin  suture  of  a  wounded  artery 
in  1759— an  operation  forgotten  for  nearly  one  hunderd  and  fifty  years 
— a  large  number  of  well-known  investigators  have  worked  at  the 
suture  problem,  especially  within  recent  years.  Lateral  arterior- 
rhaphy,  the  sewing  up  of  a  wound  in  the  side  of  an  artery,  is  now  a  well- 
recognized  procedure.  One  may  use  fine  silk  or  chromicized  catgut 
and  sew  up  the  rent  with  through-and-through  stitches.  Wounded 
veins  may  be  treated  in  the  same  fashion. 

Circular  arteriorrhaphy,  or  end-to-end  anastomosis,  is  a  more 
difficult  but  far  m(jre  interesting  operation.  Experiments  to  this  end 
have  been  numerous,  but  the  more  popular  methods  now  in  vogue 
among  us  are  those  of  J.  B.  Murphy,  by  invagination,  and  of  Alexis 
Carrel  and  Charles  C.  Guthrie,  by  direct  marginal  suture.  Carrel's' 
method  is  likely  to  prove  the  more  popular.  The  experimental  work 
has  already  demonstrated  the  possibility  of  transplanting  organs,  limbs, 
and  heads  even,  and  gives  promise  of  developing  into  a  great  and 
valuable  new  field  of  surgery. 

Surgery  of  the  Lymphatic  System 

Of  late  5'ears  writers  have  been  telling  us  that  the  lymphatic  system 
is  becoming  increasingly  important  to  the  surgeon.  I  doubt  how 
that  may  be.  The  lymphatic  system  has  always  been  important — 
probably  never  more  so  than  in  the  old  days  of  sepsis,  when  operation 
W'ounds  were  continually  infected,  with  a  complicating  extension  of 
inflammation  through  the  neighboring  lymphatic  vessels. 

Surgery  of  the  lymphatic  system  deals  wath  the  lymph-channels 
and  with  the  lymph-nodes.  The  old  term  "lymph-gland"  is  a  mis- 
nomer. The  nodes  which  occur  frequently  through  the  lymphatic 
system  are  not  glands.  They  are  not  secretory  organs,  but  rather  filters 
and  reservoirs.  The  lymph-channels  are  subject  to  two  important 
types  of  affection — occlusions  and  inflammations.  The  lymph-nodes 
also  are  subject  to  two  main  varieties  of  affections — new-growths  and 
inflammations,  in  which  respect,  indeed,  they  resemble  true  glands, 
though  the  spread  of  disease  through  the  lymphatic  system  is  pecu- 
liarly active. 

1  Rudolph  Matas,  The  Suture  in  tlie  Surgery  of  the  Vascular  System,  1906;  also 
Keen's  Surgery,  vol.  v. 

2  Alexis  Carrel,  formerly  of  Lyons,  now  at  the  Rockefeller  Institute,  New  York 
City. 


SURGERY    OF   THE    LYMPHATIC    SYSTEM  793 

Here  is  Fischer's  classification  of  these  aiJnicnts: 

AFFECTIONS  OF  THE  LYMPH-VESSELS: 

L  Acute  inflammation  of  the  lym])li-vessels. 

2.  Chronic,  non-specific  infianmiation  of  the  lymph-vessels. 

3.  Tuberculosis  of  the  lymph-vessels. 

4.  Lymphangitis  syphihtica. 

5.  Carcinosis  of  the  lymph-vessels. 

6.  Dilatation  of  the  lymph-vessels. 

AFFECTIONS  OF  THE  LYMPH-NODES: 

1.  Acute  inflammation  of  the  lymph-nodes. 

2.  Chronic,  non-specific  inflammations  of  the  lymph-nodes. 

3.  Tuberculosis  of  the  lymph-nodes. 

4.  Syphilis  of  the  lymph-nodes. 

5.  Primaiy  tumors  of  the  lymph-nodes, 

6.  Secondary-  tvmiors  of  the  lymph-nodes. 

7.  Lymphadenocele. 

Such  a  classification  is  admirable,  so  far  as  it  goes,  but  it  takes  no 
account  of  those  diseases  resulting  in  obstruction  of  the  lymph-channels, 
with  secondary'  hj-pertrophy  of  the  adjacent  tissues,  frequently  due 
to  the  organisms,  filarise,  and  resulting  in  the  diseases  of  which  lym- 
phangiectasis  and  elephantiasis  are  the  most  conspicuous. 

A  few  words  upon  the  physiology  of  the  lymphatic  system.  We 
recall  that  there  are  four  different  types  of  lymph,  according  to  Hall : 

L  Tissue  lymph,  which  fills  the  intercellular  spaces  throughout  the 
body. 

2.  Circulating  lymph,  which  passes  through  the  lymph  capillaries 
into  the  circulatory  system  by  the  way  of  the  thoracic  duct. 

3.  Chyle,  the  peculiar  circulating  lymph  of  the  intestinal  tract,  which 
carries  nutritive  material. 

4.  Serous  lymph — the  contents  of  the  serous  cavities. 

All  these  fluids,  except  chyle,  contain  at  least  95  per  cent,  of  water 
and  nearly  -1  per  cent,  of  proteids. 

To  quote  the  excellent  statement  of  Roswell  Park,  the  lymph  is 
the  only  fluid  which  comes  into  contact  with  all  the  living  cells  of  the 
body.  Blood,  on  the  other  hand,  comes  into  contact  with  the  endo- 
thehal  ceUs  only  of  the  vessels,  and  with  those  cells  in  the  splenic  pulp, 
and  perhaps  other  localities  which  have  to  do  with  its  elaboration. 
These  are  but  a  minute  proportion  of  the  total  cells  of  the  body.  All 
the  other  body  cells  receive  their  nutrition  and  oxygen  from  the  lymph, 
which  takes  its  supply  from  the  blood.  Moreover,  nearly  all  the  waste 
materials  of  the  body  are  emptied  into  the  lymphatic  system,  and 
thence  into  the  blood.  Thus  one  sees  that  the  lymph  is  the  almost 
universal  vehicle  of  exchaage  between  blood  and  tissues  through  the 
body,  and  that  its  role  in  the  economy  is  of  the  highest  significance  and 
importance. 

The  larger  lymph-streams  have  been  sho-^Ti  to  flow  in  thin-walled 
vessels  with  valves,  but  the  great  bulk  of  lymph  in  the  tissues  circulates 
freely  in  spaces,  so  called,  among  the  tissue-cells. 


794 


MINOR   SURGERY — DISEASES   OF   STRUCTURE 


Let  US  first  survey  briefly  and  hastily  the  affections  of  the  lymph- 
channels. 

In  view  of  what  I  have  said  regarding  the  inevitable  presence  of 
lymph-channels  and  a  lymph  circulation  everywhere  throughout  the 
body,  we  realize  how  grave  may  be  the  infection  of  these  channels. 

LYMPHANGITIS 

Acute  lymphangitis  is  due  commonly  to  an  infection  introduced 
from  without,  although  it  may  arise  in  connection  with  some  internal 
or  systemic   derangement — for  example,   typhoid  fever  or  puerperal 


Fig.  495.— This  illustration  shows  the  application  of  the  elastic  bandage  around  the 
arm,  with  its  end  tucked  under  (Meyer  and  Schmieden). 

septicemia.  In  the  hospital  wards  and  in  general  practice  you  shall 
find  lymphangitis  of  the  arm  by  far  the  most  common  form  of  lymphan- 
gitis. The  finger  of  the  victim  is  the  seat  of  a  small  punctured  wound 
often;  thence  organisms  promptly  enter  into  the  lymph  circulation; 
they  propagate  and  spread  with  amazing  facility,  so  that  frequently 
the  main  lymph-channels  of  the  arm,  even  to  the  axilla,  are  seen  to  be 
defined  as  red,  tender  lines,  following  especially  the  course  of  the  larger 
blood-vessels.  One  or  two  nodes  above  the  external  condyle  may 
check  for  a  time  the  process,  but  quickly  it  spreads  upward  to  the  more 


LYMPHANGITIS 


795 


numerous  axillary  nodes.  If  the  disease  runs  unchecked,  there  may- 
result  thrombi,  infection  of  the  adjacent  tissues,  a  general  breaking 
down  of  the  parts,  and  extensive  abscess  formation  through  the  efforts 
of  nature  to  combat  the  poison. 

As  regards  routine  treatment,  this  is  both  local  and  general.  Vaccine 
therapy  always  should  be  employed  whenever  vaccines  can  be  secured 
but,  unfortunately,  in  the  practice  of  most  men,  vaccines,  except 
stock  aureus  vaccines,  are  not  available.  It  remains,  therefore,  to 
accept  the  best  local  and  general  treatment,  aside  from  the  vaccine 
treatment.  The  patient  should  be  stimulated  and  sustained  by  tonics 
of  strychnin,  iron,  and  whisky ;  his  bowels  and  kidneys  should  be  kept 


Fig.  496. — Zander  room  for  mechanical  therapeutics  at  the  Massachusetts  General 
Hospital  (formerly  the  old  Bigelow  amphitheater). 

active — a  factor  never  to  be  neglected;  he  should  be  kept  in  the  open 
air;  should  receive  abundant  simple  nourishment;  and,  above  all 
things,  should  not  be  forced  to  depend  upon  his  own  efforts  for  any- 
thing; he  should  be  nursed.  Good  local  treatment  consists  in  the 
encouragement  of  stasis  hyperemia  by  Bier's  method;^  the  opening 
of  all  collections  of  pus;  and  careful  bandaging  and  support  of  the 
arm,  as  described  in  Chapter  XXVI. 

We  recognize  two  forms  of  lymphangitis:  the  reticular,  in  which  a 
minute  network  of  vessels  is  affected,  giving  to  the  skin  an  erysipeloid 
appearance;    and  the  tubular,  which  affects  the  larger  vessels  only. 

^  I  refer  the  reader  to  the  valuable  publication  of  Willy  Meyer  and  Victor  Schmie- 
den on  Bier's  Hyperemic  Treatment,  pubUshed  in  1908. 


796  MINOR   SURGERY — DISEASES    OF   STRUCTTRE 

Commonly,  the  two  foi-nis  coexist,  while  the  treatment  is  much  the  .same 
in  lioth. 

\\'riters  discuss  antiseptic  lotions  in  the  treatment  of  lymphangitis. 
Hot,  frequently  applied  lotions  are  extremely  comforting,  and  are 
vahiable  adjuncts  to  Bier's  treatment.  They  act  by  increasing  the 
hyperemia  of  the  parts,  but  there  is  no  reason  to  suppose  that  their 
antiseptic  equalities  are  advantageous.  I  employ,  as  a  rule,  large 
poultices  of  creoHn  (1:  200),  changed  every  two  hours. 

Chronic  lymphangitis  is  a  rather  uncommon  outcome  of  such  an 
infection  as  I  have  described.  The  condition  is  annoying  rather  than 
dangerous.  The  lymph-channels  are  obstructed;  the  tissues  may  or 
may  not  become  thickened  and  brawny,  while  interference  with  the 
function  of  the  parts  is  more  or  less  likely.  The  patient  should  be  given 
an  out-of-doors  Ufe,  good  food,  and  exercise,  and  if  possible  should  have 
daily  massage,  or  the  Zander  treatment,  over  the  affected  region. 

Tuberculosis  of  the  lymph-vessels  is  always  associated  with  tuber- 
culosis of  the  lymph-nodes.  The  vessels  become  somewhat  thickened 
and  tender,  but  tuberculosis  of  the  lymph-channels  alone  is  relatively 
insignificant  from  the  point  of  view  of  both  prognosis  and  treatment. 
In  Chapter  XXII,  I  have  already  discussed  tuberculosis  of  the  lymph- 
channels  and  nodes  of  the  neck.  The  disease  there  shows  us  the  typical 
points  of  lymphatic  tuberculosis. 

Syphilitic  lymphangitis  exists.  Carcinosis  of  the  lymph-vessels  con- 
cerns us,  and  I  shall  have  something  to  say  on  this  subject  in  the  chapter 
on  Tumors  (Chapter  XXVIII). 

LYMPHANGIOMA,    LYMPH    VARICES,    LYMPHANGIECTASIS,    AND 
LYMPHADENOCELE 

These  are  terms  used  variously  to  denote  obstruction  and  dilata- 
tion of  lymph-channels.  Tumors  and  enlargements  result  from  obstruc- 
tion; usually  they  are  congenital,  sometimes  they  are  acquired.  The 
growths  progress  rapidly;  the  channels  are  usually  filled  with  a  trans- 
lucent, milky  fluid,  probably  identical  with  normal  lymph.  These 
tumors  are  benign,  bvit  from  their  size  they  may  cause  distress. 

Lymphangiomata  spring  from  lymph-channels;  they  consist  of 
the  dilated  channels,  bound  together  with  a  framework  of  connective 
tissue.  The  resulting  tumor  resembles  the  common  hematogenous 
angioma. 

Lymph  varices  resemble  closely  ordinar^^  varices. 

Ljmaphangiectasis  also  is  a  term  applied  to  collections  of  dilated 
lymph-vessels — dilated  from  obstniction.  The  causes  of  such  obstruc- 
tions are  numerous  and  the  resulting  conditions  manifold.  Common 
causes  are  cicatrices,  tumors,  and  ascites,  while  the  most  frequent 
cause  leading  to  chronic  obstruction  is  the  presence  of  the  Filaria  san- 
guinis communis.  In  tropical  countries  especially  this  chronic  lym- 
phatic obstiTJction,  known  as  filariasis,  is  of  extreme  importance. 
The  jilarium  is  a  parasitic  worai  which  Hves  in  the  lymphatics  and 


LYMPHANGIOMA,    LYMPH    VARICES,    LYMPHANGIECTASIS  797 

blood-vessels  of  man.  It  gives  off  an  enormous  number  of  ova,  from 
^^•hit•ll  embryos  quickly  develop  and  circulate  in  the  blood.  They 
may  be  found  readily,  especially  at  night,  for  during  the  day  they  are 
confined  to  the  abdomen  and  thoi-acic  vessels.  They  are  active;  their 
length  is  about  4  nun.;  their  diameter  that  of  a  red  blood-corpuscle. 
Certain  mosquitos  carry  them. 

The  sympto7vs  of  JUariasis  are  not  necessarily  severe,  but  the  patient 
may  be  a  life-long  sufferer,  and  may  have  to  endure  great  and  con- 
tinued discomfort.  Swellings  appear  in  various  parts  of  the  body — 
l}'mph  tumors.     The  groin  in  particular  is  affected,  and  there  follow 


Fig.  497.— Elephantiasis  (^INIassachusetts  General  Hospital). 

various  forms  of  elephantiasis,  especially  of  the  scrotum,  the  "vailva, 
and  the  legs.  Patients  may  have  chills  and  fever,  and  are  especially 
subject  to  erysipelas  and  other  concurrent  infections.  This  elephan- 
tiasis is  due,  as  a  rule,  to  the  same  causes  which  produce  the  swelling 
in  lymphadenocele, — to  the  plugging  of  the  lymph-vessels, — ^but  the 
disease  is  local,  especially  in  the  skin  and  subcutaneous  tissues,  where 
there  is  a  chronic  hyperplasia.  We  make  the  diagTiosis  sure  by  finding 
filaria  in  the  blood. 

The   treatment   of  fdariasis  is   still  unsatisfactory.     We   have  no 
specific  drug  which  can  destroy  the  parasite.     Lacking  that,  our  best 


798  MINOR    SURGERY — DISEASES    OF    STRUCTURE 

course  is  to  remove  the  patient,  if  possible,  from  the  afflicted  region ;  and, 
by  surgical  measures,  to  remove  the  tumor  growths  so  far  as  possible. 
All  this  is  far  from  satisfactory,  and  the  surgery  is  far  from  brilliant. 
Our  hope  for  future  treatment  lies  in  the  discovery  of  a  proper  chemical 
antidote. 

LYMPHADENITIS 

Adenitis,  or  acute  inflammation  of  the  lymph-nodes,  follows  such  an 
infection  as  I  have  described  in  speaking  of  lymphangitis.  We  think 
of  the  lymph-nodes  as  barriers  or  filters.  They  hold  up  the  advancing 
organisms  and  are  themselves  in  turn  infected  and  destroyed.  There 
is  good  reason  to  believe  that  new  lymph-nodes  may  develop  after 
the  destruction  of  the  old  ones. 

The  inflammation  and  swelling  of  certain  nodes  are  recognized 
by  surgeons  as  suggesting  certain  definite  sites  of  infection.  For 
example,  inflammation  of  the  nodes  in  Scarpa's  triangle  suggests  an 
initial  lesion  in  the  foot;  inflammation  of  the  nodes  along  Poupart's 
ligament  suggests  a  lesion  of  the  genitalia;  inflammation  of  the  nodes 
behind  the  elbow  suggests  a  lesion  of  the  hand;  inflammation  of  the 
nodes  in  the  axilla,  a  lesion  of  the  hand,  arm,  or  breast;  an  abscess 
immediately  below  the  mastoid  suggests  an  infection  of  the  scalp,  often 
from  head-lice;  while  inflamed  nodes  in  the  anterior  triangle  of  the 
neck  point  to  damage  about  the  mouth,  lips,  tongue,  throat,  and  face. 

The  symptoms  of  acute  inflammation  of  the  lymph-nodes  are 
the  familiar  symptoms  of  developing  abscess,  to  which,  from  time 
immemorial,  surgeons  have  attached  the  tenns,  dolor,  calor,  rubor, 
tumor,  and  functio  Icesa.  The  pain  is  due  to  tension  upon  the  delicate 
nerve  terminals;  the  heat  is  due  to  the  increased  blood-supply  which 
nature  throws  into  the  part  in  her  endeavor  to  meet  the  bacterial 
invasion;  the  rubor,  or  redness,  may  or  may  not  be  apparent,  depending 
on  the  nearness  of  the  abscess  to  the  skin;  the  swelling  or  tumor  is 
always  present;  while  impairment  of  function  is  due  to  the  pain  of 
movement  rather  than  to  any  actual  destruction  of  the  nerves  or 
muscles. 

The  treatment  of  these  infected  lymph-nodes  (infected  by  P30- 
genic  organisms)  can  be  nothing  short  of  free  incision,  with  the  evacua- 
tion of  the  broken-down  lymph-structures ;  free  crucial  incision,  because 
a  straight  incision  may  glue  up  and  not  allow  the  wound  to  heal  from 
the  bottom,  as  it  should. 

Sometimes  the  abscess  formation  in  a  node  may  be  prevented  if 
the  source  of  infection  be  eliminated  promptly  by  treating  the  infected 
node  with  poultices,  with  lead  iodid  ointment  (10  per  cent.) ;  or  with 
Bier's  cupping-glasses.^  As  a  rule,  however,  these  infected  lymph- 
nodes  should   be  opened,   thoroughly   cleansed,   packed  lightly  with 

1  I  do  not  agree  with  those  writers  who  see  no  advantage  in  external  applica- 
tions. Nearly  twenty-five  years  of  experience  in  large  hospital  clinics  convinces 
me  that  external  apphcations  frequently  are  not  only  of  value  in  subduing  early 
infections,  but  are  of  extreme  comfort  to  suffering  patients.  There  are  other 
remedies. 


hodgkin's  disease  799 

gauze,  and  the  parts  immobilized  (as  I  have  described  in  Chapter  XXVI) 
with  abundant,  absorbent,  elastic-compression  dressings. 

Chronic  lymphadenitis  may  develop  out  of  an  acute  lymphaden- 
itis, or  may  be  slowly  progressive  from  the  start.  The  condition  is 
common  enough,  and  is  not  always  noteworthy.  A  great  many  per- 
sons have,  in  various  parts  of  the  body,  small,  slightly  enlarged  lymph- 
nodes  which  never  trouble  them.  Should  these  nodes  become  trouble- 
some, they  may  be  removed  easily. 

Tuberculous  lymph-nodes,  on  the  other  hand,  have  marked  and 
distinct  dangers.  Tuberculous  lymph-nodes  of  the  neck  give  rise  to 
that  condition  known  in  the  old  days  as  scrofula,  a  term  long  since 
abandoned.  I  have  already  discussed  tuberculous  lymphadenitis  of 
the  neck  in  Chapter  XXII,  and  merely  remind  the  reader  here  that, 
through  the  cavity  of  the  mouth  and  through  the  tonsils,  tuberculous 
organisms  can  enter  the  lymph  circulation.  For  this  reason  some 
90  per  cent,  of  all  tuberculous  lymph-nodes  are  in  the  neck.  We  treat 
the  disease  in  reasonably  robust  persons  by  enjoining  an  out-of-doors 
life.  If  the  infection  be  progressive,  however,  we  must  excise  all  the 
affected  parts. 

HODGKIN'S  DISEASE 

Hodgkin's  disease  is  quite  another  ailment  than  ordinary  lymph- 
adenitis, and  it  has  been  described  under  many  names,  such  as  adenia, 
adenoid  disease,  adenolymphoma,  splenic  anemia,  etc.  In  a  monograph 
before  me  I  find  31  terms  used  to  indicate  Hodgkin's  disease,  yet  the 
exact  nature  of  the  ailment  is  not  clear  to  us.  Some  authors  maintain 
that  it  is  tuberculous;  others,  that  it  arises  from  sundry  infecting 
organisms  not  yet  identified;  others  that  it  is  sarcomatous.  Hodgkin's 
disease  manifests  itself  in  a  great  swelling  of  the  lymph-nodes  and 
of  the  spleen.  The  disease  is  not  common,  and  the  best  present  author- 
ity asserts  that  it  is  not  to  be  confounded  with  splenic  anemia.  The 
enlargement  of  the  nodes  depends  upon  an  overgrowth  of  the  cells 
and  of  the  lymphocytes — hence  the  term,  lymphocystomata;  while 
many  of  the  cases  are  characterized  by  histologic  changes  resembling 
a  chronic  inflammatory  process  with  proliferation  of  endothelial  and 
reticular  cells,  the  formation  of  giant-cells,  and  the  presence  of  many 
eosinophiles  with  a  progressive  fibrosis.  As  Warthin  states,^  the  clinical 
complex  of  Hodgkin's  disease  has  at  present  no  pathologic  entity,  but 
may  be  produced  by  a  variety  of  conditions  quite  different  in  nature. 
We  make  the  diagnosis  by  the  aid  of  the  microscope,  and  limit  the 
term  Hodgkin's  disease  to  that  ailment  in  which  the  enlarged  lymph- 
nodes  are  of  a  chronic  imflammatory  type. 

The  clinical  course  is  somewhat  as  follows:  The  patient  is  com- 
monly a  young  man  in  good  health,  who  observes  a  swelling  on  the  side 
of  his  neck.  This  enlarges,  and  similar  swellings  appear  elsewhere — 
on  the  other  side  of  the  neck,  in  the  axillae,  the  groins,  and  the  great 
body  cavities.  The  tumors,  if  of  rapid  growth,  are  soft;  if  of  slo^W 
*  Osier's  Modern  Medicine,  vol.  iv,  p.  829. 


800  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

growth,  thoy  are  hard.  The  nodes,  at  first  discrete,  eventuall}'  merge. 
Deformity  may  be  great.  The  spleen  may  become  enormous.  The 
patient  experiences  no  pain  or  soreness.  Suppuration  does  not  occur, 
but  there  develops  extreme  anemia,  weakness,  emaciation,  cachexia. 
There  is  slight  occasional  fever,  there  is  progressive  dyspnea,  loss  of 
appetite,  indigestion,  headache,  and  dizziness.  The  limbs  become 
edematous;  a  general  anasarca  develops,  the  patient  becomes  progres- 
sively more  feeble,  and  dies  at  last  of  exhaustion. 

The  hhod  examination  shows  a  diminution  of  all  the  peculiar  con- 
stituents of  the  blood,  but  there  is  no  marked  disproportion  between 
the  red  and  the  white  corpuscles.  The  hemoglobin  may  be  very  low. 
Cultures  from  the  blood  and  nodes  are  sterile. 

The  treatment  of  Hodgkin's  disease,  after  such  a  description,  is 
obviously  unsatisfactory.  We  know  no  specific  remedy.  Surgery,  or 
rather  the  knife,  can  do  no  more  than  palliate  the  symptoms,  and  occa- 


.  -J, 


r'>|  /7-..f<.-<i^l 


Fig.  498. — Hodgkin's  disease  (Massachusetts  General  Hospital). 


sionall}^  relieve  deformity.  There  is  good  evidence  that  ai-senic  helps — 
arsenic  begim  in  small  doses,  which  are  gradually  increased  up  to  the 
limit  of  tolerance,  when  a  small  dose  again  is  given  and  the  process 
repeated, 

Hodgkin's  disease  at  the  present  day  is  exercising  the  ingenuity  of 
the  surgeon  as  well  as  of  the  physician;  w'e  know  not  what  it  is,  and 
the  tendency  of  modem  re.search  stimulates  us  to  further  investigations. 

Malignant  disease  of  the  Ijmiph-nodes,  especially  cancer,  is 
relatively  rare  as  a  "primary  disease.  Secondary  cancer  of  the  lymph- 
nodes  is  extremely  common.  I  shall  discuss  these  matters  in  the 
chapter  on  Tumors.  Sarcoma  of  the  Ijonph-nodes  is  primary  often 
enough.  The  tumor  includes  usuall)'-  a  group  of  nodes.  It  is  smooth, 
movable,  painless,  and  grows  rapidly.  The  neoplasm  invades  neighbor- 
ing tissues,  and  metastases  occur  in  the  internal  organs.  ^Mien  the 
tumor  is  situated  in  the  neck  it  may  compress  fatally  the  windpipe  and 


MUSCLES  801 

gullet;  while  in  its  last  stages  this  form  of  sarcoma  is  marked  by  per- 
foration of  the  skin,  by  hemorrhage,  and  by  suppuration.  The  diag- 
nosis is  difficult  in  the  early  stages  of  the  sarcoma,  and  the  prognosis  is 
always  grave. ^ 

Surgery  of  the  Muscles,  Tendons,  and  Bursje 

MUSCLES 

Lesions  of  muscles  seem  almost  to  belong  to  the  subject  of  minor 
surgery.  Muscle  damage  is  cared  for  by  nature  herself  in  the  great 
majority  of  cases,  yet  there  are  certain  muscle  lesions  with  which  the 
surgeon  should  be  familiar  as  a  part  of  his  general  training. 

Muscles  are  subject  to  atrophy,  and  muscular  atrophy  may  be 
simple  or  associated  with  degenerative  changes — fatty  or  amyloid. 
Simple  muscular  atrophy  concerns  us  most  nearly,  and  is  due  commonly 
to  long-continued  disuse  of  the  muscle  from  such  causes  as  paralyses 
and  the  surgeon's  splinting.  In  anterior  poliomyelitis  the  muscles 
atrophy  as  their  associated  nerves  become  functionless,  so  that  as  a 
result  of  this  disease  we  may  find  the  muscles  replaced  by  connective- 
tissue  bands.  These  are  the  so-called  sclerosed  muscles,  which  are  less 
common  than  the  soft,  flabby,  atrophic  muscles.  The  results  of  mus- 
cular atrophy  appear  as  various  deformities.  For  example,  when  the 
extensors  of  the  foot  are  thrown  out  of  action,  the  opposing  healthy 
muscles  go  to  work,  draw  the  foot  down,  and  throw  it  into  a  condition 
of  paralytic  club-foot. 

Of  recent  years  we  have  heard  a  good  deal  about  Volkmann's  con- 
tracture, or  ischemic  atrophy.  This  condition  is  seen  mostly  in  the 
forearm,  and  is  due  usually  to  the  long-continued  application  of  overtight 
splints  and  dressings.  Commonly,  the  flexor  group  of  muscles  becomes 
densely  infiltrated,  and,  unless  the  splints  are  removed  within  a  day  or 
two,  must  degenerate.  Usually  portions  of  the  muscles  undergo  sub- 
sequent contraction.  The  patient  may  or  may  not  suffer  pain,  since 
pain  in  these  cases  depends  upon  an  associated  neuritis  which  is  not 
always  present.  The  deformity  of  a  Volkmann's  contracture  is  per- 
manent, crippling,  and  unsightly.  The  forearm  and  hand  appear 
greatly  emaciated,  the  fingers  are  flexed  on  each  other,  but  the  meta- 
carpophalangeal articulations  remain  extended.  In  extreme  cases 
the  wrist  becomes  flexed  as  well  as  the  fingers. 

The  treatment  of  cases  of  muscular  atrophy  is  concerned  with  removal 
of  the  cause;  provision  for  proper  and  sufficient  nutriment;  exercise; 
prevention  of  deformity.  That  is  to  say,  we  must  keep  the  patient 
in  prime  condition;  supply  him  with  expert  daily  massage  and  elec- 
tricity; and  place  the  affected  limb  in  such  a  position  that  traction 
deformities  in  extension  shall  not  arise. 

As  to  Volkmann's  contracture — in  early  cases  massage  may  result  in 

^  I  refer  the  reader  who  would  study  more  fully  the  surgical  diseases  of  the 
lymphatics  to  Charles  N.  Dowd's  article  in  Bryant  and  Buck's,  American  Practice 
of  Surgery,  vol.  ii,  p.  525. 

51 


802 


MINOR    SURGERY — DISEASES    OF    STRUCTURE 


a  cure.  Later,  when  the  contraction  is  well  established,  we  must 
operate  in  one  of  two  ways — by  lengthening  the  flexor  tendons,  or 
by  shortening  the  radius  and  ulna  to  compensate  for  the  contracture  of 
the  muscles;  or  we  may  combine  the  two  maneuvers.  At  the  best,  the 
resulting  function  of  the  arm  is  far  from  perfect. 

Muscles  become  injiamed — myositis.      There  is  simple  myositis,  so 
called,  and  there  is  infective  7nyositis.     Simple  myositis  is  not  a  true 

inflammation ;  it  results  from  an 
injury  which  damages  the  con- 
nective tissue  of  the  muscle  and 
causes  the  formation  of  granula- 
tion tissue.  The  process  is  a 
process  of  repair,  and  ends  in 
the  substitution  of  scar  tissue 
for  muscle  tissue. 

Infective  myositis  is  rare.  The 
abundant  blood-supply  of  the 
muscles  fights  off  infections,  as  a 
rule,  but  an  infection  once  started 
may  clestro}^  large  muscle  areas. 
Muscle  tissue  eventually  may  be 
lost;  scar  tissue  may  be  substi- 
tuted for  muscle  tissue,  and 
sometimes  cartilage  or  bone  even 
may  develop  within  the  muscle 
itself.  This  last  condition  is 
designated  myositis  ossificans. 
There  is  a  progressive  form  of 
this  disease  which  begins  early 
in  life,  involves  the  muscles  of 
the  back,  and  eventually  renders 
the  patient  helpless.  A  wretched 
creature  of  this  type  will  be 
shown  in  a  museum  as  *'  the  ossi- 
fied man."  Myositis  ossificans 
of  a  milder  type  may  result  from 
injuries,  but  it  is  capable  of  cure 
through  surgical  operations. 
Tuberculosis  may  also  invade  and  destroy  muscles. 
In  all  these  forms  of  myositis  surgical  operations  may  be  of  great 
benefit.  Acutely  infected  muscles  should  be  laid  open  and  treated  on 
antiseptic  principles,  and  the  resulting  deformities  and  contractures 
should  be  treated  by  exercises,  the  lenglhening  of  tendons,  and  by  nerve 
transplantations.     Tuberculous  muscles  should  be  excised. 

Syphilis  and  actinomycosis  involve  muscles.  Syphilis  must  be 
treated  constitutionally,  while  actinomycosis  must  be  attacked  with 
vigor — with  the  knife,  curet,  and  copper  salts — as  I  have  described  in 
Chapter  II. 


Fig.  499. — Volkmann's  contracture. 


THE   TENDONS  803 

Hydatid  cysts  may  bo  treated  by  injections  of  mercury  biniodid, 
by  excision,  and  by  drainage.  Complete  excision  is  the  preferable 
method. 

Trichiniasis  is  distinctly  a  muscle  affection.  The  embryos  of 
the  trichina  spiralis  enter  the  muscle  through  the  blood-stream. 
The  flat  muscles  are  those  usually  involved.  The  embiyos  become 
encapsulated  and  die,  leaving  small,  hard,  calcified  nodules.  When 
the  parasites  are  numerous  in  the  muscles,  they  cause  pain  and  sweUing, 
with  general  symptoms  of  prostration,  loss  of  appetite,  and  edema 
of  the  extremities.  The  disease  is  self-limited.  Surgery  can  do  Httle 
for  it,  but  while  it  lasts  the  patient  should  be  treated  with  purgatives 
and  tonics. 

Malignant  tumors  appear  in  the  muscles.  The  carcinomata  are 
secondary,  but  the  sarcomata  often  are  primary.  They  are  primary  in 
voluntary  muscles,  and  arise  from  the  connective  tissue  and  from  the 
muscle  sheaths.  Moreover,  they  are  more  common  in  women  than  in 
men.  Angiomata  also  occur  in  the  muscles,  and  the  various  granulo- 
mata.     All  such  tumors  must  be  excised  promptly  and  thoroughly. 

Injuries  to  muscles  are  of  considerable  interest  to  surgeons. 
Muscles  are  ruptured  in  whole  or  in  part  by  direct  violence.  For 
example,  the  rectus  femoris  often  is  partly  ruptured  in  football  by  a 
kick.  I  have  seen  the  biceps  ruptured  in  violent  lifting.  These  muscle 
ruptures  may  or  may  not  involve  the  muscle  sheaths.  The  diag-nosis 
is  not  difficult.  Commonly  a  hernia-like  tumor  appears.  When  you 
ask  the  patient  to  "put  up"  his  muscle,  the  corresponding  limb  does 
not  move  normally,  but  a  bunch  appears  in  the  neighborhood  of  the 
damage,  and  a  well-marked  groove  may  be  seen  and  felt  below  the 
bunch.  No  man  can  state  definitely  and  positively  the  extent  of  the 
injury  in  one  of  these  cases  of  muscle  rupture.  I  have  seen  a  damaged 
rectus  abdominis  the  cause  of  a  medicolegal  suit,  when  an  ill-advised 
physician  swore  positively  that  the  muscular  belly  was  ruptured,  but 
that  the  sheath  was  intact.  The  accurate  determination  of  the^  con- 
dition properly  requires  careful  dissection  by  a  competent  anatomist. 

Nevertheless,  it  is  an  easy  matter  to  determine  some  degree  of  damage 
to  the  suspected  muscle;  while  the  treatment  demanded  is  definite 
and  obvious.  The  surgeon  should  cut  down  upon  the  injured  structure 
and  should  repair  it  with  sutures.  The  after-care  of  the  wound  is 
important.  The  parts  should  be  put  in  splints,  with  extreme  relaxa- 
tion of  the  wounded  muscle,  and  should  be  kept  immobiHzed  and  free 
from  all  violence  for  at  least  six  weeks.  We  obtain  excellent  recoveries 
under  this  treatment. 

THE  TENDONS 

The  tendons  also  are  subject  to  their  own  peculiar  lesions.  The 
student  who  would  gain  a  proper  comprehension  of  the  lesions  of  the 
motor  mechanism  of  the  body  must  not  think  of  that  mechanism's 
various  parts  as  independent.  Those  parts  are  interdependent,  and 
though  their  individual  lesions  may  seem  unrelated,  we  must  remember 


804  MINOR    SURGERY — DISEASES    OF    STRUCTURE 

always  that  they  may  be  closely  I'elated.  The  motor  mechanism  is 
composed  grossly  of  bones,  nuiscles,  tendons,  antl  nerves.  Their  re- 
lationships are  as  intimate,  and  their  disease  processes  as  difficult  of 
conventional  differentiation,  as  are  the  relationships  and  disease  proc- 
esses of  the  digestive  organs  which  1  have  described  in  Part  I  of  this 
book. 

Inflammations  and  tumors  of  bone  freciuently  involve  or  cripple 
the  action  of  muscles,  tendons,  and  nerves.  Affections  of  the  nerves  may 
destroy  the  functions  and  stmcture  even  of  bones  and  muscles.  In  like 
manner  diseases  of  the  tendons  and  tendon-sheaths  may  produce 
anatomic  and  functional  changes  in  the  bones,  muscles,  and  nerves. 

The  tendons  which  we  must  biiefly  consider  here  are  embryologi- 
cally  and  structurally  parts  of  the  muscles,  but  they  are  subject  to  ail- 
ments more  frequently  than  are  the  muscles  themselves.  The  tendons 
suffer  early  from  acute  infective  processes;  they  are  subject  to  tumor 
formations;  they  become  involved  frequently  in  chronic  infections 
originating  in  other  structures,  and  their  surgery  is  intimately  depend- 
ent upon  paralyses  due  to  nerve  lesions. 

Traimiatic  tenosynovitis  ^  is  recognized  as  a  definite  entity.  It 
is  an  affection  mo.st  commonly  of  the  tendons  about  the  wrist  or  ankle. 
The  disease  is  properly  an  ailment  of  the  tendon-sheaths,  but  the 
tendons  themselves  become  directly  involved.  The  disease  originates 
from  some  strain  or  blow  which  causes  a  congestion,  a  roughening,  and 
an  exudation  within  the  tendon-sheath.  This  is  a  condition  which 
we  associate  commonly  with  the  term  "  sprain."  At  first  the  distressed 
tissues  are  free  from  infection;  hence  we  speak  of  non-infective  teno- 
synovitis; but  should  the  lesion  remain  long  untreated  and  become 
chronic,  pathogenic  organisms  may  find  a  nidus  there,  with  a  resulting 
serious  infection,  inflammation,  and  disablement. 

In  another  place  (Chapter  XX^'I)  I  have  discussed  massage,  and 
have  sketched  its  method  of  action.  Massage  is  essentially  the  remedy 
for  these  cases  of  S3Tiovitis — massage  or  some  similar  agent — Bier's 
hyperemia  and  electricity,  for  example,  which  improve  the  circulation, 
break  up  and  hinder  adhesions,  and  promote  a  prompt  return  to  nor- 
mal efficiency. 

The  appearance  of  the  affected  parts  (sprain)  is  characterl.stic,  and 
the  symptoms  are  familiar.  The  soft  tissues  are  swollen,  edematous, 
and  tender.  There  is  always  subcutaneous  hemorrhage,  which  in  a 
few  days  may  stain  the  skin  varying  shades  of  yellow,  dark  purple,  or 
even  black.  All  movements  are  painful  and  are  involuntaiily  restricted. 
Later,  as  the  swelling  subsides  and  the  exuded  serous  fluid  is  absorbed 
from  the  tissues,  limited  movements  become  possible— especially  pas- 
sive movements,  while  the  examiner's  hand  laid  flat  and  gently  upon 
the  affected  part  perceives  often  a  pricking  or  grating  about  the  tendons. 

Active  treatment,  such  as  massage,  is  imperative  in  these  cases.  The 
old-time  immobilization  with  splints  or  a  plaster  bandage  is  an  un- 
pardonable offense. 

^  The  term  "  thecitis"  is  sometimes  employed  instead  of  "  tenosynovitis." 


THE    TKNDONS  805 

Infective  tenosynovitis  is  ;i  fur  more  serious  matter.  It  may  be 
acute  or  clironic.  The  acute  form  results  commonly  from  septic 
wounds  about  the  distal  insertions  of  the  tendons.  Felon,  palmar 
abscess,  and  inflammatory  ingrowing  toe-nail  are  common  sources  of 
tenosynovitis,  and  the  most  familiar  location  by  far  is  in  the  hand 
and  wrist.  The  surrounding  parts  become  tensely  swollen,  red,  hot, 
edematous,  and  painful.  The  lymph-channels  are  involved;  the 
muscles  are  invaded;  and  the  whole  limb  takes  on  that  angry  appear- 
ance familiarly  known  to  us  as  the  ''septic  arm."  The  patient  suffers 
quickly  from  a  systemic  invasion.  His  temperature  nms  high;  his 
pulse  is  bounding  and  quick;  he  experiences  loss  of  appetite,  constipa- 
tion, and  diminished  renal  action  until  the  disease,  if  not  successfully 
treated,  results  in  a  septicemia  and  the  death  of  the  sufferer.  These 
infections  are  less  common  than  of  old,  but  even  now  they  are  greatly 
to  be  dreaded,  and  they  demand  energetic  treatment. 

Treatment. — We  need  not  here  consider  in  minute  detail  the  manage- 
ment of  septic  infections  beyond  reminding  ourselves  again  that  treat- 
ment is  two-fold — general  and  local.  We  must  stimulate  the  bowels 
and  kidneys;  calomel  catharsis  and  abundant  water-drinking  usually 
suffice.  We  may  well  prescribe  citrate  of  iron  and  quinin  in  10-grain 
doses;  but,  most  important  of  all,  we  must  ascertain  the  nature  of  the 
invading  organism,  and  must  supply  the  patient's  circulation  with  the 
indicated  opsonins.     The  Bier  bandage  also  is  of  great  value. 

Such  general  measures  must  be  supplemented  by  local  treatment. 
We  must  open  all  collections  of  pus— open  them  freely  and  widely  with 
long  incisions;  we  must  clean  out  necrotic  tissue;  we  must  wash  thor- 
oughly the  parts  with  formalin,  hydrogen  dioxid,  and  sterile  water: 
and  keep  open  the  wounds  with  gently  applied  gauze  wicks  for  drainage 
— not  wdth  tightly  packed  iodoform  gauze  stuffing.  These  operations 
must,  of  course,  be  done  with  the  patient  under  a  general  anesthetic, 
preferably  nitrous  oxid  or  ether.  Often  the  tedium,  pain,  and  throb- 
bing of  these  wounds  may  be  relieved  by  placing  the  affected  limb  in  a 
hot  sterile  bath  for  hours  at  a  time.  Sometimes,  in  spite  of  our  most 
zealous  endeavors,  the  bones  become  involved  in  the  infective  process, 
so  that  we  are  forced  to  corrective  amputations. 

Acute  and  chronic  tenosynovitis  may  also  arise  from  various 
organisms  reaching  the  seat  of  action  through  the  blood-  and  lymph- 
streams.  Among  these  organisms  the  gonococcus  of  Neisser  plays  an 
important  role.  A  so-called  idiopathic  tenosynovitis,  associated  with 
edema,  pain,  loss  of  function,  and  other  evidences  of  inflammation, 
should  always  lead  the  surgeon  to  the  investigation  of  a  possible  ante- 
cedent gonorrhea  in  the  patient.  The  commonly  accepted  treatment  is 
absolute  rest,  with  immobilization  of  the  parts,  while  the  primary 
gonorrhea,  if  present,  must  be  combated  at  the  same  time.  Friedreich 
maintains  that  multiple  small  skin  incisions  or  punctures  are  essential. 
Certainly,  this  measure  gives  great  relief;  some  observers  are  encouraged 
to  use  the  gonococcus  vaccines  also  in  these  cases. 

Tuberculous  tenosynovitis,  sometimes    called    "compound   gan- 


806 


MINOR    SURGERY — DISEASES    OK    STKlCTrRE 


glion/'  is  an  obstinate,  chronic,  and  cxtrcincly  troublesome  affection. 
The  tendon-sheaths  become  tubcrcuUnis  and  obstructed;  fkiid  collects 
in  the  confined  sjjaces  within  them;  an  oblong  c\-stic  tumor  results.  The 
disease  may  remain  self-limited  at  this  stage,  or  gradually  may  advance 
so  as  to  involve  several  tendon-sheaths  and  the  surrounding  parts. 
The  ancient  method  of  rupturing  this  "ganglion"  with  a  blow  is  futile. 
The  surgeon  should  dissect  out  carefully  all  the  diseased  tissues;  should 
close  the  wound  completely  with  a  proper  skin-flap;  should  innnobilize 
the  limb  for  a  number  of  weeks,  and  should  prescribe  emphatically  a 
proper  hygienic  lif(\ 

Tumors  of  the  tendon-sheaths  are  rare.  Perhaps  lipomata  are  the 
least  rare,  while  connective-tissue  tumors  have  been  recognized.  These 
tumors  must  be  treated  by  careful  and  thorough  excision. 


Fig.  500.— Ganglion. 


Paronychia,  felon ,  and  jiabnar  abscess  are  described  in  Chapter  XXVI. 

I  have  spoken  of  tuberculous  ganglion;  there  is  a  non-infective 
ganglion  also — a  cystic  tumor,  appearing  usually  on  the  dorsal  side  of 
the  carpus.  It  is  associated  with  little  pain  and  is  troublesome  mainly 
from  the  slight  disability  and  weakness  which  it  causes.  This  foim  of 
ganglion  also  must  be  removed  by  excision,  and  I  prefer  the  crescentic 
skin  incision. 

Wounds  of  tendons  are  common  enough.  I  have  already  explained 
how  infected  wounds  of  the  tendons,  such  as  those  resulting  from  felon, 
must  be  cleaned  out  and  allowed  to  heal  from  the  bottom.  Infected 
tendons  and  their  sheaths  propagate  sepsis  with  extreme  rapidity,  and 
demand  energetic  treatment. 

Clean  wounds  of  the  tendons,  especially  operative  wounds,  must  be 
treated  on  quite  another  plan.     The  tendons  must  be  sought  out,  and 


THE   TENDONS  807 

carefull}-  upproximatod  and  sutured,  for  the  purpose  of  restoring  func- 

P 


mm 


Fia  501  — lUustratine  various  methods  of  dealing  witli  tendons  in  tendoplasty  (after 
^-        '  ""  Vulpius). 

tion.     This  operation  is  somewhat  similar  to  the  operation  of  nerve-su- 
turing.     Unlike  severed  nerves,  however,  severed  tendons  retract  from 


808  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

sight,  owing  to  the  pull  of  the  muscles  above.  For  this  reason,  if  several 
tendons — e.  g.,  the  flexors  of  the  wrist — are  severed  at  once,  it  will  be 
difficult  or  impossible  to  approximate  truly  each  stump  to  its  fellow. 
But  in  any  case,  the  surgeon  must  do  his  best.  Use  fine  silk  sutures  to 
draw  the  tendons  together  and  employ  the  technic  illustrated  in  the 
figures.  If  possible,  repair  accurately  the  tendon-sheaths.  So  far  the 
operation  goes  well  enough,  and  the  result  may  seem  admirable.  Un- 
fortunately, adhesions  may  form  between  the  tendons  and  the  skin,  so 
that  free  play  of  the  tendon  is  delayed  or  becomes  pei-manently  lost 
even.  Aseptic  precautions  in  the  operation  are  imperative.  A  slight 
fault  in  the  technic  will  result  in  imperfect  repair  and  in  uncertain 
function. 

Tendon  transplantation  ^  for  the  relief  of  paralyses  has  been  a 
favorite  operation  with  orthopedic  surgeons  during  the  past  fifteen 
years.  In  these  days  we  are  substituting  for  it  nerve  transplantation. 
The  best  results  of  tendon  transplantation  have  been  attained  in  cases 
of  anterior  poliomyelitis  in  which  one  year  at  least  has  elapsed  since 
the  onset  of  the  disease;  and  the  tendons  employed  have  been  commonly 
those  of  the  leg  below  the  knee.  The  technic  of  this  operation  is  most 
painstaking,  and  the  surgeon  attempting  it  should  study  carefully  the 
larger  monographs  on  the  subject,  and  should  obtain  the  advice  of  an 
experienced  neurologist. 

THE  BURS.E 

The  bursse  deserve  the  seiious  attention  of  surgeons — never  more 
than  to-day,  when  the  intricate  relations  of  bursse  with  the  joints  are 
becoming  more  obvious  than  formerly. 

Bursitis  of  various  forms  is  the  subject  of  our  study,  and  bursitis 
may  or  may  not  be  infective.  Indeed,  the  forms  of  bursitis  are  quite 
similar  to  the  forms  of  tendon-sheath  inflammation,  for  both  stmctures 
are  made  up  on  similar  lines. 

Traumatic  bursitis  results  from  injuries,  and  is  manifested  at  first 
by  swelling,  pain,  tenderness,  and  loss  of  function;  later  by  atrophy 
of  the  parts,  stiffness  of  the  neighboring  joints,  and  pain  on  motion. 
One  of  the  most  interesting  types  of  this  form  of  bursitis  is  inflammation 
of  the  subdeltoid  bursa,  which  E.  A.  Codman  has  described  in  a  series 
of  brilliant  monographs.-  The  studies  of  this  writer  show  that  this 
bursa  is  more  extensive  than  the  anatomies  have  taught,  and  that  its 
relations  are  intimate,  not  only  with  the  shoulder-joint,  but  with  the 
associated  tendons,  especially  with  the  rotator  group. 

The  suprapatellar  bursa  (or  bursse),  the  bursa  beneath  the  liga- 
mentum  patellce,  the  bursa  behind  the  olecranon,  and  many  other  similar 
bursse  are  of  great  surgical  importance.  These  bursas,  when  damaged  by 
blows,  become  deeply  injected,  and  secrete  an  abundant  fluid,  which 
may  be  hemorrhagic;    M-hile  later,  when  the  fluid  becomes  absorbed, 

1  H.  Augustus  Wilson,  The  Advantages  of  Tendon  Transplantation,  Amer.  Med., 
April  8,  1908. 

2  Transactions  Massachusetts  Medical  Society,  1908. 


THE    BURS^E 


809 


there   may   result   adhesions   between   the   opposino;   bursal   surfaces. 
These  are  the  atlhesions  whicli  cause  permanent  crippling  and  pain. 


Fig.  502. — Diagram  from  frozen  section.  Notice  the  deltoid  and  its  origin  from 
the  edge  of  the  acromion.  Notice  the  subdeltoid  or  subacromial  bursa  with  its  roof 
made  by  the  under  surface  of  the  acromion  and  by  the  fascia  beneath  the  upper  por- 
tion of  the  deltoid.  Its  base  is  on  the  greater  tuberosity  and  the  tendon  of  the  supra- 
spinatus  which  separates  it  like  an  interarticular  fibrocartilage  from  the  true  joint 
(E.  A.  Codman). 

The  treatment  of  traumatic  bursitis  may  be  extremely  simple,  or  it 
may  be  intricate  and  prolonged.  The  freshly  damaged  limb  should 
be  immobilized  in  a  position  to  relax  the  overlying  muscles — the  arm 


Fig.  503.- — Illustrating  the  condition  which  would  be  found  in  abduction,  the 
tuberosity  having  passed  under  the  acromion  and  the  point  {b)  having  passed  the 
point  (a).  The  elastic  deltoid  has  taken  up  the  slack  at  one  end  and  the  supra- 
spinatus  at  the  otlier.  It  is  obvious  that  the  floor  of  the  bursa,  as  it  lies  on  the 
tendon  of  the  supraspinatus  and  the  tuberosity,  must  be  a  smooth,  even,  round 
surface.  As  a  matter  of  fact,  the  first  time  one  cuts  into  the  bursa  one  is  almost 
startled  to  find  how  much  the  floor  of  it  looks  like  the  cartilaginous  surface  of  the 
bone.  It  is  obvious  that  if  the  surfaces  of  the  bursa  bet\\een  the  points  a  and  b  in 
Fig.  502  were  adherent,  it  would  be  impossible  for  the  joint  to  pass  into  the  position 
shown  in  Fig.  503  (E.  A.  Codman). 


somewhat  elevated,  in  the  case  of  subdeltoid  bursitis;  the  leg  extended 
in  the  case  of  prepatellar  bursitis}     If  the  effusion  into  the  bursa  per- 


^  Prepatellar  bursitis  is  known  by  the  ancient  term 
olecranon  bursitis  is  commonly  called  "  mit^er's  elbow." 


'  housemaid's  knee."    Post- 


810 


MINOR    SURGERY — DISEASES    OF    STRUCTURE 


SuPrt>«3/»//VATl 


Fig.  504. — A  diagrammatic  representation  of  a  horizontal  section  through  the 
liead  of  the  humerus  to  indicate  the  lateral  extent  of  tlie  l)urRa,  and  the  necessity 
for  its  existence  to  allow  the  greater  tuberosity  to  rotate  beneath  the  deltoid.  Notice 
also  how  the  tendon  of  the  subscapularis  is  stretched  around  the  head  in  the  opposite 
direction  in  external  rotation.  This  stretching  occurs  not  in  the  tendons  themselves, 
which  are  very  short,  but  in  the  muscles  which,  by  their  construction,  take  up  the 
slack  of  the  capsule  of  the  joint.  In  fact,  the  capsule  of  the  joint  is  really  made  up 
of  the  tendons  and  muscular  heUies  of  these  short  rotators.  It  can  easily  l)e  imagined 
how  a  simultaneous  spasm  of  these  muscles  would  lock  the  joint,  for  in  the  normal 
motion  one  must  relax  as  the  otlier  contracts.  Notice  also  the  cross-section  of  the 
coracobrachialis  and  the  necessity  for  the  subcoracoid  bursa  which  lies  between 
it  and  the  subscapularis.  Since  the  two  muscles  work  at  right  angles  to  one  another 
the  bursa  is  indispensable  (E.  A.  Codman). 


See  Fig.  504  (E.  A   Codman). 


THE    BURSyE 


811 


Fig.  506. — Dotted  line  showing  incision  used  for  demonstration  of  the  bursa.    For  en- 
largement see  Fig.  507  (E.  A.  Codman). 


Fig.  507. — Illustrates  the  appearance  when  an  incision  is  made  into  the  normal  bursa 

(E.  A.  Codman). 

sists  for  more  than  ten  days,  the  bursa  should  be  opened,  evacuated, 
wiped  out  with  95  per  cent,  carbolic  acid,  followed  by  70  per  cent. 


812  MIXOU   SURGERY — DISEASES   OF   STRUCTURE 

alcohol,  and  closed  securely  without  drainage.  If  pain  and  impaired 
function  follow  the  subsidence  of  distention,  the  sur<ieon  siiould  employ 
massage,  Bier  cupping,  and  passive  movements,  with  intervals  of 
immobilization.  Usually  four  or  five  weeks  of  such  treatment  will 
establish  a  cure,  except  in  the  cases  of  subdeltoid  and  subcoracoid 
bursitis/  which  are  often  so  obstinate  as  to  cripple  the  victim  for  months 
or  years  even. 

Acute  infective  bursitis  is  due  either  to  a  punctured  wound  or  to 
a  hematogenous  infection.  The  acutely  inflamed  bursa  calls  for  prompt 
and  radical  treatment.  It  should  be  opened  freely,  the  sac  excised,  and 
the  cavity  swabbed  out  with  carbolic  and  alcohol  or  with  Harrington's 
solution.     The  wound  should  be  packed,  but  not  closed  tightly. 

Chronic  bursitis  may  result  from  an  acute  bursitis,  as  in  the  case 
of  the  subdeltoid  bursa;  or  it  may  be  due  to  long-continued  irritation, 
such  as  the  pressure  of  the  boot  over  the  first  metacarpophalangeal 
joint — pressure  which  gives  rise  to  a  bunion.  I  have  descnl)ed  bunion 
in  Chapter  XXVI.  Chronic  bursitis  is  best  treated  hy  excision  of  the 
bursa. 

Tuberculosis  of  bursae  is  a  fairly  common  condition,  difficult  at 
first  of  diagnosis,  similar  in  its  morphology  to  tuberculous  tenosynovitis. 
Tuberculous  bursie  may  be  excised. 

There  are  tiunors  of  bursae  which  need  not  concern  us  further  than 
to  reflect  that  they  too  must  be  excised. 

We  have  passed  in  rapid  review  the  diseases  of  muscles,  tendons, 
and  bursse — topics  of  grave  concern  often— topics  of  acute  interest  to  the 
painstaking  surgeon  who  is  familiar  with  anatomy.  Most  of  the  opera- 
tions which  I  have  described  in  this  chapter  are  ''anatomic  operations" 
— that  is  to  say,  they  demand  of  the  surgeon  that  sort  of  minute  anatomic 
knowledge  which  was  probably  more  familiar  to  the  great  surgeons  of 
the  early  decades  of  the  nineteenth  century  than  it  is  to  the  operator 
of  to-day. 

Surgery  of  the  Skin 

Surgery  of  the  skin  concerns  the  dermatologist ;  but  certain  of  its 
phases  concern  the  general  surgeon  also;  at  those  phases  let  us  glance 
briefly. 

Dermatology  delights  in  archaic  terms,  and  we  might  well,  at  the 
conclusion  of  this  chapter,  already  too  long,  indulge  ourselves  in  sonor- 
ous classic  words.  Most  of  those  words  and  terms,  however,  pertain 
properly  to  the  domain  of  dermatolog}' — not  to  the  domain  of  general 
surgeiy,  although  the  conventional  text-book  of  surger}'  describes  at 
length  many  skin  lesions.  Such  lesions,  for  an  account  of  which  I  refer 
the  reader  to  text-books  of  dermatology,  are  comedones,  vnlium,  vwl- 
luscum  eontagiosum,  dermatitis  venenata,  dermatitis  gangrenosa,  sun- 
burn, lupus,  blastomycosis,  etc. 

There  are  certain  other  skin  lesions,  however,  with  which  the  sur- 
geon must  concern  himself.     Some  of  these  I  have  already  described 

1  Goldthwait,  Painter  and  Osgood,  Diseases  of  the  Bones  and  Joints,  p.  660. 


SURGERY   OF   THE    SKIN  813 

elsewhere  in  this  book — iren,  furuncle,  carbuncle,  corn,  callus,  nevus, 
cutaneous  horns,  nntlignant  disease  of  the  skin. 

There  remain  a  half-dozen  or  more  skin  affections  which  we  must 
consider  here — burns,  cicatrices,  frost-bites,  chilblains,  keloid,  and  malig- 
nant degeneration  of  scars  and  ulcers  (Marjolin's  ulcer) . 

Burns  are  not  necessarily  and  properly  limited  to  the  skin  surface. 
The}-  vary  in  depth,  and  according  to  their  depth  we  define  them  as 
of  the  first,  second,  and  third  degrees.  The  first  degree  is  characterized 
by  a  simple  erythematous  inflammation,  sometimes  followed  by  desqua- 
mation. The  second  degree  shows  inflammation  with  blisters,  which 
may  or  may  not  appear  until  a  day  or  two  after  the  injury.  The  true 
skin  is  not  destroyed.  The  third  degree  signifies  a  burn  which  destroys 
the  skin  and  underlying  structures  to  a  varying  extent. 

Any  substance  hot  or  acrid  enough  to  cause  a  necrosis  of  tissue 
will  give  rise  to  a  burn — fire,  hot  metal,  boiling  water,  boiling  oil,  acids, 
and  even  the  useful  hot-water  bag  if  long  enough  applied. 

The  depth  and  extent  of  burns  rarely  at  once  are  obvious;  while, 
unfortunately,  prognosis  depends  entirely  upon  the  depth  and  extent. 
The  shock  is  often  out  of  all  proportion  to  the  first  appearance  of  the 
injur}-;  and  the  patient,  if  he  recovers,  may  do  so  after  weeks  and 
months  of  suffering,  and  may  carry  with  him  thereafter  great,  crippling, 
and  disfiguring  scars.  A  wide  burn  of  the  limbs  or  of  the  head  even 
may  not  necessarily  kill  the  patient,  while  a  relatively  small  bum  of 
the  trunk  shortly  may  cause  death.  Shock  and  pain  are  leading 
syni'ptoms  at  first,  and  these  symptoms  may  be  succeeded  by  internal 
inflammations,  such  as  pneumonia,  pleurisy,  meningitis,  peritonitis, 
and  duodenitis  (leading  to  ulcer).  There  is  often  marked  leukocytosis; 
the  urine  is  high  colored,  scanty,  and  loaded  with  albumin  and  casts. 

The  early  deaths  are  undoubtedly  due  to  shock;  the  late  deaths,  to 
pyemia  or  to  some  other  general  infection.  Children,  aged  persons,  and 
the  alcoholic  fall  ready  victims  to  burns.  Recurrent  vomiting  is  an 
ominous  sign,  suggesting  gastric  or  duodenal  ulcer,  often  associated 
with  hemorrhage. 

The  treatment  of  burns  is  symptomatic,  and  is  directed  to  the  vary- 
ing degrees  of  burns.  In  the  burns  of  iYiQ  first  degree  we  strive  to  relieve 
pain  by  anodynes  and  by  excluding  air  from  the  affected  area.  Appli- 
cations of  carron  oil  or  of  vaselin  usually  suffice  for  the  latter  purpose, 
while  immersion  of  the  part  in  a  warm  solution  of  sodium  bicarbonate 
is  grateful  to  the  patient. 

Burns  of  the  second  degree  are  treated  on  much  the  same  plan, 
except  that  the  extensive  destruction  of  the  epidermis  requires  often 
a  longer  course  of  treatment.  We  must  open  the  numerous  blebs, 
dress  them  with  drying  powders  and  ointments,  and  must  repeat  the 
dressings  frequently — sometimes  two  or  three  times  in  twenty-four 
hours.  Comforting  dressings  are  an  ointment  of  boric  acid  and  vaselin, 
Squibb's  compound  alum  powder,  or  silver  foil.  The  continuous  bath 
in  warm  soda  solution  is  extremely  comforting  and  effective. 

Bums  of  the  third  degree  test  our  resources.     Give  to  the  patient 


814  MINOR   SUKGERY — DISEASES   OF   STRUCTURE 

at  once  morphiu  sufficient  to  relieve  his  pain.  Dress  the  wound  with 
an  abundant  oily  dressing;  and  then  concentrate  effort  upon  combat- 
ing shock.  Stimulate  renal  secretion  by  the  infusion  of  normal  salt 
solution;  give  a  brisk  purge  (calomel  or  a  saline  cathartic) ;  add  adrena- 
lin to  the  infusion.  If  these  measures  fail  to  relieve  the  shock,  employ 
the  transfusion  of  blood — a  final  but  extremely  hopeful  resort. 

With  the  subsidence  of  shock  the  patient  enters  upon  a  long  course 
of  tedious  and  distressing  wound  healing,  during  which  a  great  variety 
of  remedies  may  be  employed.  The  wounds  must  be  kept  strictly 
clean  by  the  removal  of  all  sloughs,  and  by  frequent  gentle  washing 
with  such  non-irritating  lotions  as  warm  5  per  cent,  boric  acid,  or  normal 
salt  solution.  Simple  boric-acid  ointment  may  suffice  for  a  dressing. 
After  convalescence  has  been  established  it  may  be  possible  and  advisa- 
ble to  cover  the  raw  surfaces  with  skin-grafts,  if  skin  can  be  obtained.  In 
spite  of  all  these  measures  the  wounds  sometimes  remain  sluggish  for 
months,  and  show  little  tendency  to  close.  Under  such  circum- 
stances I  have  found  open-air  treatment  of  the  wounds  extremely 
effective.  The  wound  is  exposed  for  many  hours  of  the  day,  or  con- 
tinuously, to  the  open  air,  while  we  protect  it  properly  from  dust  and 
insects.  Surgeons  who  have  not  tried  this  method  will  be  astonished 
often  at  its  efficiency  in  the  case  of  obstinate  and  long-standing  granu- 
lating wounds.^ 

Superficial  cicatrices  of  great  extent,  grievously  deforming,  may 
result  from  healed  bums.  The  most  familiar  of  these  defoiining 
cicatrices  are  those  of  the  neck,  the  elbow,  and  the  wrist.  As  these 
cicatrices  contract,  the  chin  is  drawn  down  in  a  truly  hideous  fashion; 
the  elbow  is  drawn  up  so  as  seriously  to  cripple  the  arm,  or  the  wrist 
becomes  so  twisted  as  to  render  useless  the  fingers.  The  only  satis- 
factory treatment  for  these  deformities  is  some  plastic  operation,  asso- 
ciated perhaps  with  grafting.  Writers  claim  that  careful  prophylaxis 
by  extension  in  splints  during  convalescence  will  head  off  these  deformi- 
ties. I  regard  this  notion  as  Utopian.  The  less  extensive  scars  some- 
times may  be  helped  by  such  mild  measures  as  Gersuny's  method  of 
injecting  liquid  vaselin  into  the  tissue  beneath  the  cicatrix;  by  douches, 
baths,  massage,  electricity,  tenotomy.  Claude  Martin  employs  traction 
and  continuous  pressure,  which  sometimes  render  the  scars  supple. 
Occasionally  the  a;-rays  will  bring  about  absorption  of  scar  tissue. 
Such  treatment  is  applicable  to  the  milder  cases  only. 

Operative  treatment   calls  for   careful   planning  and   painstaking 

1  Extract  from  Jour.  Amer.  Med.  Assoc,  1908:  "  Hot  Horse  Servm  n?  Treatment 
of  Burns. — R.  Petit's  communications  on  the  efficacy  of  hot  horse  serum  in  local 
treatment  of  wountls  have  been  summarized  in  tliese  cohmins  from  time  to  time. 
He  now  announces  that  it  is  proving  tlie  best  topical  application  for  extensive  bums. 
The  Presse  Medicale,  June  13th,  tiuotes  some  of  his  case  histories,  sliowing  that 
healing  was  much  more  rapid  in  the  bums  treated  with  the  hot  horse  senmi  than 
in  other  burned  patches  in  the  same  cliild  treated  with  picric  or  boric  acids,  etc. 
He  beheves  that  the  horse  senmi  revi\-es  the  injured  cells,  possibly  including  tl  e 
nerve-cells,  so  that  they  recuperate  and  aid  in  the  healing  process,  instead  of  dyirg 
and  generating  poisons.  The  senmi  also  summons  the  leukocytes  to  the  spot,  wliile 
its  harmlessness  has  been  demonstrated." 


SURGERY    OF   THE    SKIfJ  815 

execution.  We  must  loosen  up  thoroughly  the  scar  tissue  in  flaps 
until  the  affected  parts  are  completely  mobilized.  We  thus  secure  a 
new  and  wide  area  of  raw  surface  which  must  be  filled  in.  Sometimes 
we  can  fill  in  the  surface  with  Thiersch  or  Wolff  grafts.  Again,  we  may 
turn  in  plastic  flaps  of  sound  skin  from  the  neighborhood,  taking  pains 
always  that  the  newly  applied  flap  shall  be  more  than  abundant,  and 
that  it  shall  lie  in  place  easily  and  without  tension.  It  is  a  mortifying 
calamity  sometimes  to  find  that  the  newly  applied  skin-flap  at  the  end 
of  four  or  five  days  is  sloughing  on  account  of  undue  tension  and  an 
insufficient  blood-supply.  We  complete  the  operation  with  carefully 
applied  and  abundant  absorbent  dressings,  which  must  be  reinforced 
by  splints,  if  necessary,  so  as  to  hold  the  parts  in  their  normal  relations. 

Frost-bite  is  a  condition  analogous  to  bum — indeed,  we  may 
recognize  three  degrees  of  frost-bite.  The  exciting  cause  ordinarily 
is  exposure  to  cold  air,  but  cold  applied  in  a  limited  fashion,  and  locally, 
may  damage  the  skin.  I  have  seen  extreme  sloughing  of  the  abdominal 
wall  follow  the  long-continued  application  of  an  ice-bag. 

The  early  symptoms  of  frost-bite  differ  materially  from  the  symptoms 
of  a  burn,  for  in  the  former  case  the  parts  become  numb  and  analgesic. 
The  analgesia  persists  just  so  far  as  the  tissues  are  necrotic.  Later,  if 
recovery  take  place,  the  patient  experiences  tingling  and  pain  with 
the  return  of  circulation  in  the  part.  That  skin  which  is  without  sensa- 
tion for  twenty-four  hours  must  be  regarded  as  dead.  We  are  warned 
against  the  diagnostic  needle-prick,  as  it  may  lead  to  gangrene. 

The  treatment  of  frost-bite  must  be  cautiously  conducted.  Patients 
should  be  kept  for  a  time  in  a  room  at  a  low  temperature,  w^hile  the 
affected  part  is  immersed  in  ice-water.  After  fifteen  minutes  the 
surgeon  or  nurse  should  take  the  limb  in  hand  and  begin  gentle  friction 
with  ice-water  or  snow.  As  the  circulation  returns  and  the  normal 
temperature  is  established,  apply  stimulating  friction  with  spirits  of 
camphor  or  alcohol  and  water.  Gradually  raise  the  temperature  of  the 
room,  and  cautiously  give  warm  drinks — hot  tea  with  a  little  rum,  hot 
bouillon,  hot  milk,  etc. 

By  such  means  the  milder  forms  of  frost-bite  may  be  successfully 
treated.  The  deeper  frost-bites,  which  destroy  tissues  and  cause 
gangrene  of  the  parts,  must  be  treated  on  general  surgical  principles — 
by  trimming  off  the  sloughs  and  by  appropriate  amputations. 

Chilblains  {erythema  -pernio)  are  localized  areas  of  impaired  circula- 
tion in  the  skin.  The  victims  commonly  are  persons  in  poor  general 
condition.  Patches  of  skin  on  the  hands  and  feet  become  bluish  or 
purple,  swollen,  tender,  cold  to  the  touch,  itching  and  burning  to  the 
sensation  of  the  patient.  Neglect  and  too  much  rubbing  make  matters 
worse,  so  that  blisters  and  ulcerations  even,  with  possible  gangrene, 
may  result. 

Treat  the  disorder  by  general  tonics,  by  protecting  the  exposed 
parts  with  proper  clothing,  by  exercise,  and  locally  by  immersing  the 
affected  region  in  hot  saturated  solution  of  alum.  In  mild  cases  balsam 
of  Peru  or  10  per  cent,  ichthyol  ointment  may  be  rubbed  in  twice  a  day. 


816 


MINOR    SI  RGERY— DISEASES    OF   STRUCTURE 


Keloid  is  a  coniioctivo-tissue  overgrowth  in  the  corium.  Some- 
times it  arises  spontaneously;  more  often  it  is  a  result  of  traumatism. 
We  call  the  spontaneous  keloid  tr'ue  keloid,  and  that  resulting  from 
injury  false  keloid.  These  growths  look  like  greatly  thickened  scars. 
Negroes  especially  are  subject  to  false  keloids,  which  may  appear  any- 
where in  the  body.  The  true  keloid  is  seen  most  commonly  over  the 
sternum. 

The  growth  is  situated  in  the  central  and  lower  portions  of  the 
cutis.     It  begins  on  the  walls  of  the  larger  vessels,  and  when  fuUv 


Fig.  508. — Extensive  keloid  of  face  (Massachusetts  General  Hospital). 


developed,  is  composed  of  dense  bundles  of  fibrous  tissue  which  are 
mostly  arranged  parallel  with  the  long  axis  of  the  tumor. 

The  patient  usually  complains  of  nothing  except  the  deformity, 
though  occasionally  there  may  be  slight  pain,  while  rarely  the  keloid 
undergoes  malignant  degeneration. 

The  treatment  of  keloid  is  far  from  satisfactory.  The  obvious  measure 
is  to  excise  the  tumor  with  a  wide  margin,  in  the  hope  of  replacing  it 
by  a  narrow  linear  scar.  Unfortunately,  in  many  cases  a  new  keloid 
appears  at  the  site  of  the  new  scar.  I  have  seen  some  excellent  resultr; 
follow  the  long-continued  use  of  the  a^-rays  after  excision  of  the  growth. 

Every  hospital  has  on  its  list  of  chronic  patients  some  of  these 
cases  of  keloid, — patients  who  return  year  after  year  to  have  their 


.SURGERY    OF    THE    SKIM 


817 


deformities  iniprovod  if  possible, — upon  wiioiu  the  surgeon  comes  to 
look  with  ever-increasin<>'  dismay. 

Malignant  degeneration  of  scars  and  ulcers  occurs  in  various 
parts  of  the  body.  Marjolin  described  the  condition  half  a  century  ago, 
and  Da  Costa  wrote  of  it  again  in  1903  (Marjolin's  ulcer).  The  term 
is  applied  to  chronic  ulcers  which  have  undergone  malignant  changes. 
Cicatricial  tissue  also  may  undergo  similar  changes.     Lupus  and  syphilis 


Fig.  509. — Keloid  (Massachusetts  General  Hospital). 

are  among  the  etiologic  factors.  The  ulcer  takes  on  malignant  charac- 
teristics about  its  margins,  and  these  malignant  changes,  when  once 
started,  may  progress  rapidly.  The  ulcer's  edges  become  hard  and 
elevated ;  the  granulations  large  and  hemorrhagic ;  there  is  often  great 
pain  and  a  fine  bloody  discharge;  the  adjoining  h^mph-nodes  become 
involved,  and  the  ulcer  runs  the  characteristic  malignant  course. 
The  treatment  is  obvious — a  prompt  and  wide  excision. 

52 


CHAPTER  XXVIII 
TUMORS 

In  this  chapter  I  propose  to  discuss  briefly  the  subject  of  tumors, 
although  by  so  doing  I  must  viohite  the  promise  in  my  introduction 
that  I  would  not  deal  in  this  work  with  matters  of  general  pathology. 

Tumors,  however,  belong  esentially  to  surgery  as  distinguished  from 
medicine.  Except  when  hopeless — and  who  may  say  what  is  hopeless? 
— tumors  have  no  place  in  medical  wards  or  under  the  care  of  the 
internist.  A  distinguished  American  surgeon  recently  said  to  me: 
"  I  visited  one  of  your  famous  hospitals  and  went  through  the  medical 
wards  with  the  visiting  physician.  He  showed  to  me  a  number  of 
patients  whose  ailment  was  cancer  of  the  stomach.  What  were  cases 
of  cancer  of  the  stomach  doing  in  the  wards  of  an  internist?  He  could 
not  cure  them."  Such  is  the  radical  surgeon's  view — and  it  is  a  view 
which  is  gaining  new  adherents  daily. 

The  term  tumor  is  a  clinical  rather  than  a  proper  pathologic  term. 
It  signifies  a  swelling  merely;  and,  literally  used,  might  well  be  applied 
to  tuberculous  joints  or  to  ascites.  Commonly,  the  physician  means 
by  the  term  tumor  a  solid  new-growth — a  neoplasm.  Roswell  Park's 
definition  is:  '■  "A  tumor  is  a  new  formation,  not  of  inflammatory  origin, 
characterized  by  more  or  less  conformity  to  the  tissue  in  which  it  has 
its  origin,  and  having  no  physiologic  function." 

The  terms  neoplasm  and  new-groivth  are  interchangeable. 

We  speak  of  benign  tumors  and  of  malignant  tumors.  A  benign 
tumor  is  a  new-growth  which  increases  by  the  proliferation  of  its  own 
intrinsic  elements  without  destroying  neighboring  structures.  It 
remains  generally  confined  to  its  own  capsule  and  causes  no  known 
hematogenous  changes.  A  malignant  tumor  is  a  new-growth  which 
spreads  unconfined,  and  destroys  neighboring  structures  as  it  advances. 
It  produces  remote  metastases;  it  is  associated  usually  with  hemolytic 
changes,  and  it  kills  the  patient. 

Benign  tumors  may  and  sometimes  do  destroy  life,  but,  as  Bland- 
Sutton  puts  it :  "  The  baneful  effects  of  innocent  tumors  depend  entirely 
upon  their  environment,  but  malignant  tumors  destroy  life,  whatever 
their  situation." 

Benign  tumors  may  become  transformed  into  malignant  tumors, 
while  there  are  inteiinediate  varieties  which  cannot  be  assigned  to 
either  group.  Uterine  myomata  may  be  multiple — one  of  these  asso- 
ciated myomata  may  require  a  saw  to  divide  it;  another  may  be  as  soft 
as  a  ripe  fig;  while  a  third  ma}^  be  as  viscous  as  jelly.  One  of  these 
^  Roswell  Park,  Modern  Surgery,  p.  255. 
818 


CAUSATION    OF  TUMORS  819 

tumors  may  remain  innocent,  while  another  may  go  on  with  changes 
of  structure  until  it  becomes  definitely  a  carcinoma. 

CLASSIFICATION 

The  classification  of  tumors  made  by  authors  is  various,  and  at 
times  surprishig.  ^\e  know  little  as  yet  of  the  etiology  of  tumors, 
and  are  unable,  therefore,  to  classify  them  on  an  etiologic  basis.  We 
group  them  accordingly,  on  a  basis  of  histology,  assigning  to  them 
names  which  designate  the  more  important  elements  in  their  stmcture. 

In  general  terms  we  can  divide  tumors  into  four  groups — cysts, 
dermoids,  connective-tissue  tumors,  and  epithelial  tumors.  Such  a  classi- 
fication is  doubtless  too  limited  for  convenient  practice,  though  it  is 
essentially  that  of  both  Bland-Sutton  and  Roswell  Park;  while  Nicholls,^ 
drawing  largely  on  the  work  of  Adami,  gives  an  extremely  complicated 
classification,  based  largely  on  the  differentiation  between  the  primary 
cell-layers  in  the  fetus — the  lepidic  or  lining  membrane  tissues;  and 
the  hylic  or  pidp  tissues.  Adami's  classification  has  certain  elements 
of  great  value,  as  it  enables  us  to  distinguish,  for  example,  the  endo- 
thelial from  the  epithelial  growths.  In  this  brief  treatise,  however,  I  shall 
employ  a  more  familiar,  even  though  unsatisfactory,  classification,  as 
follows:  (1)  Cysts;  (2)  dermoids;  (3)  teratomata;  (4)  connective-tissue 
tumors;  (5)  neuromata;  (6)  epithelial  tumors;  (7)  corium  epitheliomata; 
(8)  odontomata. 

CAUSATION  OF  TUMORS 

The  causation  of  tumors  is  one  of  the  burning  questions  of 
medical  science— a  question  so  intricate,  so  hotly  debated,  and  so  far 
from  settlement  that  I  shall  attempt  no  special  expression  of  opinion 
regarding  it  in  this  brief  and  elementary  writing.  It  is  well,  however, 
that  the  general  reader  should  have  some  notion  of  the  opinions  and 
clash  of  authorities. 

The  traumatic  cause  of  new-growths  was  accepted  without  question 
until  the  last  generation.  To-day  traumatism  as  a  cause  of  tumors 
is  regarded  variously  by  sound  observers.  Those  who  take  the  nega- 
tive side  of  the  argument  assert  that  we  have  no  positive  experimental 
evidence  that  traumatism  causes  new-growths — and  by  this  we  mean 
commonly  malig-nant  disease.  They  remind  us  that  every  patient 
who  suffers  from  malignant  disease  can  point  to  some  antecedent  injury 
to  the  part  affected ;  but,  these  critics  say,  what  person  lives  who  cannot 
recall  some  slight  injury  to  every  region  of  his  body?  Moreover, 
experimenters  have  been  unable  to  produce  neoplasms  by  purposeful 
damage  to  any  structure.  Observe,  however,  that  by  traumatism 
we  understand  not  only  immediate  and  obvious  tissue  damage  by  blows 
or  other  irritating  forces,  but  structural  disturbances,  gradually  pro- 
duced through  long-continued  sfight  pathologic  actions,  w^hich  at  first 
may  not  have  been  seriously  regarded.  In  this  latter  class  of  trauma- 
1  Bryanl  and  Buck,  American  Practice  of  Surgery,  vol.  i,  p.  294. 


820  MINOR    SURGERY — DISEASES    OF    STRUCTURE 

tisms  we  include  cluniai2;e  to  the  uterus  by  child-bearing;  damage  to 
the  stomach  by  hypcrchlorhydria,  leading  to  ulcer  formation;  damage 
to  the  gall-bladder  by  inflammatory  affections  leading  to  calculus 
formation;  damage  to  the  breast  through  lactation;  and  damage  to  the 
lip,  in  men,  through  the  habit  of  pipe-smoking — a  cause  of  damage 
as  rarely  operative  in  women  as  is  e})ithelioma  of  the  lip  in  women. 
In  view  of  such  facts  many  surgeons  have  returned  to  the  view  that 
traumatism,  especially  long-continued  traumatism,  is  a  potent  element 
in  the  causation  of  malignant  disease. 

Cohnheim's  enihryonal  hypothesis  has  been,  and  still  is,  a  favorite 
explanation  of  tumor  formation  in  a  certain  number  of  cases.  He 
founds  his  hypothesis  on  the  anomalous  embryonic  arrangements  of 
certain  cells,  and  asserts  that  in  the  early  stages  of  embryonal  develop- 
ment there  are  produced  more  cells  than  are  necessary  for  the  consti- 
tution of  a  certain  part,  so  that  a  number  of  cells  i-emain  superfluous. 
Large  groups  of  superfluous  cells  may  exist,  producing  superfluous 
organs  and  limbs  even.  In  other  cases  certain  small  groups  of  cells, 
hitherto  unrecognized,  may  be  roused  into  activity  and  pi'oduce  a 
neoplasm. 

Heredity  was  regarded  for  centuries  as  an  important  element  in 
tumor  formation,  but  we  have  little  reliable  evidence  that  it  is  im- 
portant. 

The  parasitic  theory  of  tumor  formation  has  become  popular  within 
recent  years.  New  evidence  in  its  favor  is  being  accumulated  and 
new  arguments  are  being  advanced.  The  controversy  is  now  with  us, 
but  I  feel  that  it  is  no  part  of  this  writing  to  deal  with  a  ciuestion  so 
recent,  of  a  literature  so  voluminous,  and  so  far  from  solution. 

CYSTS 

A  cyst  is  a  sac  distended  with  fluid.  The  sac  may  contain  a  single 
cavity  or  it  may  be  divided  into  countless  compartments.  Cysts  result 
from  the  abundant  dilatation  of  preexisting  cavities  or  tubules.  There 
are  retention  cysts,  tubidocysts,  hydroceles  or  distention  cysts,  and  gland 
cysts. 

A  familiar  form  of  retention  cyst  is  Jiydronephrosis  due  to  ureteral 
obstruction  with  a  consequent  dilatation  of  the  renal  peh'is. 

Tubulocysts  are  cystic  dilatations  of  certain  functionless  ducts  and 
obsolete  canals.  Bland-Sutton  describes  seven  species  of  tubalo- 
cysts:  (1)  Cysts  of  the  vitello-intestinal  duct;  (2)  cysts  of  the  urachus, 
(3)  paroophoronic  cysts;  (4)  parovarian  cj^sts;  (5)  cystic  disease 
of  the  testes;  (6)  cysts  of  Gartner's  duct;  (7)  cysts  of  IMiiller's  duct. 
Several  of  these  forms  are  embryonal ;  several  of  them  are  so  extremely 
rare  as  to  be  surgical  curiosities.  I  have  already  described  in  Chapter 
XI  the  more  familiar  forms  of  cysts  connected  with  the  female  genera- 
tive organs;  and  in  Chapter  XV,  the  analogous  cysts  of  the  male  organs.* 

*  I  refer  the  reader  who  seeks  more  detailed  knowledge  to  Bland-Sutton's  exhaus- 
tive article  in  Keen's  Surgery,  vol.  i,  p.  863,  and  to  Albert  G.  Nicholls'  essay  in 
American  Practice  of  Surgery,  vol.  i,  p.  291. 


CYSTS 


821 


Nicholls  reminds  us  of  the  important  distinction  between  cysts  and 
cystomula.  In  general  teims  we  may  define  a  cyst  as  a  patliologic 
cavity  containing  Iluid;  but  av(>  do  not  think  of  new  formed  tissue  as 
a  cyst  of  this  type.  A  cystotna  is  a  true  neoplasm,  resulting  from  the 
proliferation  of  a  matrix  that  tends  to  form  cavities. 

Cysts  of  the  vitello-intestinal  duct  make  themselves  evident  com- 
monly in  small,  cherry-like  tumors,  red,  soft,  and  velvety,  connected 
with  the  navel  by  slender  pedicles.     These  tumors  are  derived  from 

the  intestinal  canal,  as  their  histology 
shows.  They  are  easily  removed  with 
the   cautery. 


Fig.  510. — Cyst  of  the  mesentery 
(Vander  Veer). 


Fie   511.— Congenital  cyst  of  the  pelvis 
(Ahlfeld). 


Cysts  of  the  urachus  or  cord  passing  from  the  urinary  bladder 
to  the  naval  are  quite  rare.  They  are  difficult  of  diagnosis  also,  and 
suggest  a  distended  bladder,  rather  than  any  of  the  more  comrnon 
forms  of  cysts.  These  cysts  may  be  easily  removed  and  the  communica- 
tion with  the  bladder  closed  through  an  abdominal  section. 

Echinococcus  cysts  ((Tania  echinococcus)  are  due  to  an  mtestmal 
worm  whose  normal  habitat  is  the  dog.  The  worm  is  about  4  mm.  m 
length  and  consists  of  four  segments,  of  which  the  fourth  and  largest 
only  becomes  mature.  These  creatures  produce  enormous  quantities 
of  eo-gs  which  may  be  conveyed  with  food  to  the  viscera  of  man.  ihere 
they  mature  and  the  resulting  embryos  pass  into  the  blood-vessels  and 


822 


MINOR    SURGERY — DISEASES    OF    STRUCTURE 


are  conveyed  to  various  organs,  especially  the  liver.  In  the  organs 
of  the  afflicted  person  the  embryos  becomes  transformed  into  cysts, 
commonly  called  hydatid  cysts}  Each  cyst-wall  has  a  peculiar  struc- 
ture—an external  elastic  layer,  and  an  inner  layer  of  granular  matter, 
cells,  muscle  tissue,  and  a  vascular  system.  These  cysts  are  held  in 
a  fibrous  capsule,  and  are  maintained  within  it  in  a  fluid  medium.  If 
one  removes  this  fluid  by  tapping,  the  external  capsule,  or  so-called 
"mother  cyst,"  at  once  collapses,  while  the  fluid  withdrawn  is  found  to 
contain  numerous  small  ''daughter  cysts,"— suggesting  grape-skins,-- 
hooklets,  and  various  other  constituents,  such  as  sodium  chlorid,  succinic 
acid,  and  occasionally  leucin,  ty rosin,  and  sugar. 


Fig.  512. — Portion  of  a  liver  wliich  weighed  25  pounds  tl:oroughly  infested  with 
echinococcus  cysts  (Bland-8utton). 

Echinococpus  disease  is  peculiar  especially  to  certain  latitudes, 
and  is  endemic  in  Iceland.  A  patient  from  Iceland,  who  is  the  victim 
of  a  tumor,  should  always  be  suspected  of  echinococcus  disease. 

The  syr7iptoms  and  diagnosis  of  echinococcus  disease  depend  entirely 
upon  the  location  of  the  disease,  whether  in  the  liver,  kidney,  brain,  or 
elsewhere.  In  general  terms,  we  find  that  the  damage  caused  by  the 
disease  is  in  direct  proportion  to  the  size  of  the  cyst  and  to  its  interfer- 
ence with  the  function  of  the  organ  in  w^hich  it  lies.  As  a  general  rule, 
the  diagnosis  is  made  by  accident  in  the  course  of  an  operation,  the 

1  The  word  "hydatid"  means  properly  an  encysted  re.s/r/e.  It  is  not  ai)plied  to 
echinococcus  disease  alone,  as  many  think. 


CYSTS 


823 


surgeon  having  explored  the  affected  region  with  the  purpose  of  evacuat- 
ing pus  or  I'enioving  a  tumor. 

As  to  the  trcattnent  of  this  disease,  I  have  hinted  at  it  in  the  fore- 
going i)aragraph.     In  most  cases,  owing  to  the  deep  site  of  the  tumor 


Fig.   513. — An  echinococcus  cyst,  showing  the  peculiar  lamination  of  its  walls 

(Leuckart). 


and  its  relation  to  the  vital  organs,  it  cannot  be  removed  entire,  but 
must  be  subjected  to  drainage  and  to  long-continued  irrigation  with 
such  aseptic  fluids  as  potassium  permanganate  or  weak  bichlorid  solu- 
tion. Rarely,  the  surgeon  may  be  able  completely  to  enucleate  the 
"mother  cyst." 

As  for  hydrocele,  I  have  already  discussed  specific 
instances  of  the  disease,  such  as  hydrocele  of  the  tunica 
xaginalis,  hydrocele  of  the  cord,  eic,  hydrocele  of  the  neck 
is  an  ancient  term  used  to  describe  cystic  collections  of 
congenital  origin  due  to  dilatation  of  the  branchial 
ducts.  Neck  hydrocele  is  far  from  common,  and  is 
generally  mistaken  for  a  deep  abscess  or  for  masses  of 
tuberculous  glands. 

Ranula  is  the  common  example  of  a  gland  cyst. 
It  is  a  retention  cyst,  due  to  obstruction  of  the  sub- 
maxillary or  sublingual  ducts. 

There  are  pseudocysts  which  properly  are  distended 
diverticula,  such  as  I  have  already  described  as  spring- 
ing from  the  esophagus  or  intestine. 

There  are  so-called  neural  cysts;  for  example,  hydro- 
cephalus smd  spina  bifida. 

In  other  chapters  of  this  work  I  have  dealt  with  the 
various  characteristics  of  special  forms  of  cysts.  It  is 
needless  here  to  repeat  those  descriptions  beyond  re- 
minding the  student  that  in  most  cases  cysts  are  readih'  amenable  to 
operative  treatment,  but  that  permanent  cure  depends  upon  the  de- 
struction and  removal  of  the  cyst-wall,  and  not  upon  its  simple  drain- 
age— an  ancient,  easy,  and  fatuous  procedure. 


X.I2 

Fig.  514.— 
Taenia  echino- 
coccus (Leuck- 
art). 


824  MINOR    SURGERY — DISEASES   OF    STRICTURE 

DERMOIDS  AND   TERATOMATA 

Dermoids  and  teratomata  '■  are  tumors  often  confounded  with  each 
other  by  the  thoughtless  speaker.  Indeed,  they  are  conditions  of 
distinctly  different  origin. 

Dermoids  are  cysts  or  tumors  containing  tissues  and  ap})ontlages 
which  are  developed  from  the  epiblast.  .\  sim])le  form  of  dermoid  is 
a  cyst  whose  interior  is  lined  with  skin  bearing  hair  and  sebaceous 
glands.  The  cavity  of  such  a  cyst  is  usually  filled  with  a  mixed  thick 
lifjuid  made  up  of  fat,  water,  cholesterin,  and  growing  hairs.  A  common 
location  of  dermoids  is  in  the  median  line  and  in  the  region  of  the 
embryonic  fissures.  We  see  dermoids  of  the  back  associated  with 
spina  bifida  and  dermoids  over  the  sternum.  There  are  dermoids  of 
the  scalp,  which  are  frequently  called  wens,  and  dermoids  of  the  dura 


'^ff^' 


Fig.  515. — Solid  dermoid  tumor  escuiiiiig  from  the  pelvis  (Park). 

mater  even.  Dermoid  cysts  are  found  most  commonly  in  the  ovary 
and  may  there  attain  a  large  size. 

Sometimes  these  forms  of  tumor  may  degenerate  into  sarcomata, 
or  may  even  develop  as  cancers. 

In  their  ordinary  form,  and  when  non-malignant,  dermoid  cysts 
cause  such  symptoms  as  we  should  expect  from  an}'  other  benign  tumor, 
encroaching  upon  organs  and  interfering  with  their  functions. 

The  treatment  is  radical  extirpation,  and  the  extirpation  must  be 
thorough  indeed,  for  if  any  of  the  epithelial  lining  of  the  cyst  be  left, 
a  new  tumor  of  similar  type  is  likely  to  form. 

Teratomata  are  structures  far  more  complicated  than  are  dermoids. 
They  may  contain  mere  fragments  of  embryonic  tissue,  or  they  may 
contain  portions  of  jaws,  teeth,  limbs,  and  even  the  trunk  of  a  partially 
^  Dermoid,  from  derma,  skin;   teratoma,  from  icrata,  monstrosity. 


DERMOIDS    AND    TERATOMATA 


825 


formed  embryo.  The  so-called  "double  monsters,"  museum  curiosi- 
ties, properly  are  teratomata. 

Bland-Sutton's  definition  is:  "A  teratoma  is  an  irregular  con- 
glomerate mass  containing  the  tissues  and  fragments  of  viscera  belong- 
ing to  a  suppressed  fetus,  attached  to  an  otherwise  normal  individual. 
It  is  a  significant  fact  that  external  teratomata  are  found  almost  ex- 
clusively in  connection  with  the  vertebral  column  and  skull." 

As  Koswell  Park  states :  "  The  presence  of  supernumerary  members 
is  largely  connected  with  what  is  called  dichotoryiy,  alluding  thereby 
to  cleavage  either  at  the  anterior  or  posterior  end  of  the  developing 
embryo.  When  the  whole  embryonic  axis  divides,  twins  may  be  pro- 
duced, but  should  the  cleavage  be  partial,  we  may  have  a  monster  with 
two  heads,  if  it  be  anterior;  or  one  with  three  or  more  limbs,  if  it  be 
posterior." 


Fig.  516. — A  postrectal  dermoid  with  hair  and  a  tooth  (Bland-Sutton). 

More  commonly,  however,  the  surgeon  finds  teratomata  as  tumors 
within  the  abdomen  or  thorax,  or  upon  the  face  or  neck,  and  these 
tumors  may  contain  a  few  vertebrae  or  processes  resembling  fingers  or 
portions  of  viscera.  Such  a  tumor  may  be  found  in  the  larynx  also, 
hanging  by  a  small  pedicle,  or  in  the  sacral  or  coccygeal  regions. 

Teratomata,  like  dermoids,  may  take  on  malignant  changes,  which 
condition  seems  to  lend  strong  support  to  Cohnheim's  hypothesis  re- 
garding the  origin  of  tumors. 

The  symptoms  and  the  treatment  of  teratomata  differ  in  no  obvious 
degree  from  the  symptoms  and  treatment  of  dermoids,  as  I  have  de- 
scribed them. 


826  MINOR  SURGERY — DISEASES   OF   STRUCTURE 

TUMORS  OF   THE  CONNECTIVE-TISSUE   TYPE 

Tumors  of  the  connective-tissue  type  constitute  a  large  class — 
probably  a  majority — of  all  tumors;  and  we  divide  them  into  two  main 
groups — the  benign  and  the  malignant.  A\'e  need  not  here  consider 
in  detail  the  structure  and  characteristics  of  all  these  growths,  but 
we  may  well  name  them  severally,  and  glance  at  those  factors  in  their 
make-up  and  their  life  history  which  are  of  special  interest  to  surgeons. 

A  lipoma  is  a  tumor  composed  of  fat,  and  is  one  of  the  most  common 
of  new-growths.  There  are  encapsulated  lipomata  and  diffuse  lipomata, 
the  former  being  surrounded  with  a  sheath  of  fibrous  tissue,  while  the 


Fig.  517. — Lipoma  uf  shoulder.     Removed.     Local  ane.stliesia  (author's  case). 

latter  e.xtend  in  all  directions  without  a  well-marked  fibrous  limit. 
Encapsulated  lipomata  are  found  in  all  parts  of  the  body — under  the 
skin,  the  serosa,  and  the  mucosa;  within  the  joints;  and  beneath  the 
peritoneum.  These  encapsidated  lipomata  are  more  or  less  intimately 
adherent  to  their  fibrous  sheaths.  Sometimes  one  may  be  shelled 
readily  out  of  its  sheath — sometimes  it  must  be  removed  by  careful 
dissection.  As  with  all  benign  tumors,  lipomata  cause  disablement 
just  so  far  as  they  interfere  with  function.  A  fatty  tumor  as  large  as 
a  dinner-plate,  when  situated  between  the  shoulders,  is  not  troublesome. 
A  fatty  tumor  the  size  of  a  man's  thumb,  if  it  protrude  into  the  knee- 
joint,  may  cause  great  pain  and  result  in  serious  crippling.  The 
"lipoma  arborescens"  of  Midler  is  xhe  common  example  of  the  latter 


TUMORS    OF  THE    CONNECTIVE-TISSUE   TYPE 


827 


form,  the  joint  lipoma,  and  is  often  associated  with  rheumatoid  arthritis. 
Subserous  lipomata  situated  behind  the  peritoneum  may  attain  enormous 
size;  may  occur  at  almost  any  age;  may  seriously  interfere  with  visceral 
function;  and  may  be  mistaken  for  grave  abdominal  tumors.  Diffuse 
lipowata  are  seen  most  commonly  on  the  back  of  the  neck.  Such 
lipomata  spread  without  a  limiting  barrier  and  may  cause  ugly  de- 

fo  unities. 

The  treatment  of  all  forms  of  Hpomata  is  excision.  Those  encapsu- 
lated growths  which  are  found  on  the  anterior  surface  of  the  body 
may  b'e  shelled  out  readily,  while  lipomata  of  the  hack  call  for  a  more 
painstaking  dissection.      Deep-seated   encapsulated   lipomata  usually 


Fig.  olS. — Dissection  of  lipoma  of  shoulder. 

may  be  scooped  out  without  great  trouble.  Per  contra,  diffuse  lipomata 
must  be  removed  with  the  greatest  care  in  order  that  no  portion  of  the 
growth  remain.  This  form  of  fatty  tumor  recurs  unless  it  be  removed 
thoroughly. 

A  fibroma  is  a  tumor  composed  of  fibrous  tissue;  and  the  pure 
fibroma  is  not  especially  common.  Mixed  fibromata  occur  often 
enough,  however,  such  as  fibrolipomata,  fibromyomata,  fibrosarcomata, 
and  the  like.  We  find  the  pure  fibromata  in  the  female  generative 
organs,  the  intestine,  the  gums,  nerve-sheaths,  and  skin.  Even  so, 
manv  of  these  pure  fibromata  are  mere  curios.  Certain  of  the  fibromata 
of  the  gums  and  skin  have  been  already  described  in  other  chapters. 
I  have  mentioned  also  those  fibrous  tumors  termed  desmoids— smaM 


828  MIN(JR    SURGERY — DISEASES    OF   STRUCTURE 

growths  springing"  from  the  muscles,  tendons,  and  aponeuroses.  Rarely 
they  may  attain  a  c'onsidera))le  size.  A  psammoma  is  a  hard  fibrous 
tumor  of  the  dura  mater.  Psammomata  are  fairly  common  intra- 
cranial tumors,  and  though  benign,  they  may  destroy  the  patient  through 
gradually  increasing  intracranial  pressure. 

A  chondroma  is  a  tumor  composed  of  hyaline  cartilage.  It  is  usu- 
ally found  connected  with  the  epiphyses  of  the  long  bones.  Chondro- 
mata  are  dense,  hard,  and  immovable  when  young;  but  when  mature 
they  may  be  the  seat  of  cystic  degeneration.  They  may  become  calci- 
fied or  ossified. 

The  treatment  of  chondromata  is  not  always  easy.  Obviously,  they 
call  for  thorough  excision,  but  thorough  excision,  if  it  compromise  the 


^' 


Fig.  519. — Diffuse  lipoma  TMassachusetts  General  Hospital). 

epiphyses  of  the  long  bones  of  young  persons,  may  result  in  a  permanent 
shortening  of  the  limb.  On  the  other  hand,  the  chondroma  ma}-  attain 
a  great  size,  and  may  so  far  involve  the  integrity  of  the  bone  that  its 
removal  implies  the  amputation  of  the  limb.  One  may  see  that  the 
removal  of  chondromata  may  call  for  the  highest  degree  of  experience 
and  skill,  and  that  each  individual  case  must  be  treated  upon  its  individ- 
ual merits. 

An  osteoma  is  a  bone  tumor,  which  we  must  distinguish  from  an 
exostosis  and  from  an  odontoma.  Exostoses  are  irregular  outgrowths 
of  bone,  while  osteomata  are  distinct  tumors  composed  of  bone-like 
tissue;  and  odontomata  are  tumors  of  dental  origin  and  structure. 
Moreover,  osteomata  may  be  regarded  as  ossifying  chondromata. 


TUMORS   OF   THE   CONNECTIVE-TISSUE   TYPE 


829 


As  for  exostoses,  wo  l)()ii-()w  from  Bland-Sutton  a  ('la.ssification  of 
three  forms:  (1)  Those  ])roduce(l  by  ossification  of  tendons;  (2)  sub- 
ungual exostoses  which  grow  beneath  the  toe-nails;    (3)  exostoses  due 


Fig.  520. — Osteoma  of  skull  (author's  case). 

to   calcification  of  inflammatory  exudates,   including  that   condition 
known  as  myositis  ossificans. 


Fig.  521. — Osteoma  of  mandible  (redrawn  from  Bland-Sutton). 

The  treatment  of  these  bony  tumors  is  quite  similar  to  that  of  cartilage 
tumors.  Thorough  removal  usually  suffices  for  a  cure — rarely  we  must 
amputate. 

Sarcoma.^ — It  is  hard  to  see  just  whj^  the  ancients  applied  the 

1  ffop^,  flesh;  sarcoid,  resembling  flesh. 


830  -MIXOK    SLHGKHY — DISEASES   OF   STRUCTURE 

term  "fleshy  tumor"  to  this  growth,  for  many  of  its  forms  resemble 
grossly  certain  forms  of  cancer.  At  any  rate,  the  term  "sarcoma" 
was  loosely  used  until  recent  years,  and  was  applied  to  many  varieties 
of  tumor.  To-day  "sarcoma  means  a  tumor  composed  of  immature 
mcsoblastic  or  embryonic  tissue  in  which  cells  predominate  over  inter- 
cellular material."'  Or,  as  Bland-Sutton  puts  it:  ''A  sarcoma  may 
be  regarded  as  a  malignant  tumor-disease  of  connective  tissue."  Ac- 
cordingly, it  may  arise  in  any  part  of  the  body  where  connective 
tissue  exists — and  connective  tissue  is  omnipresent.  Moreover,  sarco- 
mata know  no  limitation  of  age. 

Commonly,  hitherto  we  have  tlivided  sarcomata  into  three  classes, 
according  to  the  shape  of  their  cells  and  theii' disposition:  (1)  Round- 
cell;    (2)   spindle-cell;    (3)  myeloid. 


Fig.  522. — Exostosis  of  the  femur  produced  by  ossification  of  the  tendon  of  the 
adductor  magnus  (Bland-Sutton). 

The  reader  of  this  book  is  familiar,  doubtless,  with  the  various 
appearances  of  sarcoma;  suffice  it,  therefore,  to  remind  him  merely  that 
the  round-cell  sarcoma  is  a  simple  structure  consisting  of  round-cells 
with  extremely  little  intercellular  substance.  Round-cell  sarcomata 
have  no  lymphatics;  they  are  extremely  vascular;  they  grow  rapidly; 
infiltrate  easily;  recur  quickly;  and  cause  numerous  metastatic  de- 
posits. It  is  said  that  the  smaller  the  cell,  the  more  malignant  the  tumor. 
Lymphosarcoma  is  a  variety  of  the  round-cell  sarcoma.  Its  numerous 
cells  are  inclosed  in  a  meshwork  resembling  that  of  a  lymph-node,  but 
the  tumor  is  in  no  way  to  be  confcnuided  with  the  granulomata  involv- 
ing lymphatic  structures. 

1  Roswell  Park. 


TUMORS   OF   THE    CONNECTIVE-TISSUE   TYPE 


831 


Spindlc-rell   sarcoma   presents   on   microscopic    section   a   different 
structure  from  the  round-cell  sarcoma.     The  cells  have  a  spindle  shape 


■0 


Fig.  523. — Large  round-cell  sarcoma  of  skin  (after  Karg  and  Schmorl). 

and  run  in  all  directions.     In  this  tumor,  again,  the  smaller  the  cell, 
the  more  malignant  the  growth.     Alveolar  sarcoma  is  a  rare  subdivi- 


Fig.  524. — Round-cell  sarcoma  (Fowler). 


sion  of  this  form.     The  spindle-cells  assume  an  alveolar  arrangement 
suggesting  the  epithelial  cells  of  carcinoma.     We  observe,  however, 


832 


MINOR   SURGERY — DISEASES    OF    STRUCTURE 


in  alveolar  sarcoma  a  delicate  reticulum  between  the  celLs — an  arrange- 
ment never  met  with  in  carcinoma. 

Myeloid  or  giant-cell  sarcoma  resembles  structurally  the  red  nuirrow 
of  growing  bone  and  contains  many  nuiltinuclear  cells  in  a  matrix  of 
round-  or  spindle-cells.  These  are  the  tumors  of  long  bones,  and  con- 
stitute also  the  majority  of  those  growths  known  as  epulis.  When 
round-cells,  spindle-cells,  and  giant-cells  are  found  in  nearh'  equal 
proportion,  the  tinnor  commonl}-  is  called  a  mixed-cell  sarcoma. 

Osteosarcoma,  as  Roswell  Park  points  out,  is  more  than  a  sarcoma 
of  bone,  for  mere  sarcoma  of  bone  may  spring  from  the  adjacent  fibrou::* 
or  the  medullary  elements.  Osteosarcoma  is  sarcoma  of  the  bone- 
forming  connective   tissue,   including  the  osteoblasts  and  the  osteo- 


/i^^r    # 


^'  r 


>^ 


Fig.  525. — Small  spindle-cell  sarcoma  of  the  skiu  \  X  250'i  ('after  Karg  and  Schmorl). 

clasts;  in  other  words,  the  stroma  of  bone.  Consequently  genuine 
bone  develops  throughout  the  tumor,  which  is  essentially  a  neoplasm. 
We  must  distinguish  these  tumors,  clinically  as  well  as  histologically, 
from  the  medullary  sarcomata  which  develop  within  the  bone,  and 
expand  it  sometimes  to  enormous  proportions,  the  bony  covering  be- 
coming a  mere  shell.  Chondrosarcoma  resembles  osteosarcoma.  It 
is  a  sarcoma  springing  from  the  stroma  of  cartilage-producing  tissue. 

Says  Bloodgood^ :  "  When  the  giant-cell  tumor  occurs  as  a  medullary 
gro'«i:h,  it  expands  the  bone  (like  a  bone  cyst).  It  may  be  as  slow  of 
growth  as  a  cyst.     The  x-ray  shadow  does  not  distinguish  it  positive!}' 

1  Joseph  C.  Bloodgood,  Conservative  Operations  on  Bone  Tumors,  Jour.  Amer. 
Med.  Assoc,  February  1,  1908. 


TUMORS   OF   THE    COXNECTIVE-TISSUE   TYPE 


833 


from  any  other  tumor  having  a  bone  shell.  This  tumor  has  been  per- 
manently cured  by  simple  cureting.  Recurrences  have  followed  cureting, 
but  were  permanently  eradicated  by  a  second  operation  of  cureting, 
resection,  or  amputation.  .  .  .  One  should  not  attempt  cureting 
unless  there  is  a  thick  shell  of  l)one,  so  that  the  curet  or  chisel  removes 
a  zone  of  bone  bej'ond  the  tumor.  ...  As  this  tumor  is  relatively 
frequent,  and  as  in  this  country  amputation  has  been  the  operation 
of  choice,  a  knowledge  of  its  (the  tumor's)  characteristic  appearances 
should  be  acquired  by  surgeons.  .  .  .  This  tumor  has  a  character- 
istic appearance  in  the  fresh  state.  When  first  seen  at  the  exploratory 
incision,  it  strikes  one  by  its  very  hemorrhagic,  mottled  coloring.     The 


.-.    "<-    ^•--       /c**"       ^'e   *fe. 


■A'>, 


5te^  -*^ 


® 


JE?  ^      * 

'^^ 

^ 

■«  *■* 

'•-•♦^ 

>^- 

y 

/ 

Fig.  526. — Giant-cell  sarcoma  of  upper  jaw  (X  250)  (after  Karg  and  Schmorl). 


majority  of  areas  are  red,  with  here  and  there  specks  or  smaller  masses 
of  a  pinkish  white.  The  tumor  is  friable  and  can  be  broken  up  into 
irregular  masses.  At  first  sight  it  resembles  hemorrhagic  granulation 
tissue,  but  it  is  firmer  and  less  succulent." 

Says  Bloodgood  further;  "I  am  of  the  opinion  that  the  term  osteo- 
sarcoma should  be  given  only  to  the  bone  tumor  associated  with  new 
bone  formation.  As  a  matter  of  fact,  this  is  observed,  to  any  extent, 
only  in  the  periosteal  tumor.  This  sarcoma  of  bone,  characterized  by 
spicules  of  new  bone  foraiation  radiating  from  the  shaft  between  which 
tumor  tissue  is  present,  occurs  most  commonly  on  the  lower  jaw.  In 
my  experience  none  of  the  cases  has  given  metastasis.  Local  resection 
should  be  the  operation.     The  tumor  has  a  distinct  capsule  and  does 

53 


834 


MINOR    SURGERY — DISEASES    OF    STRUCTURE 


not  infiltrate  the  surrounding-  muscles;    it  must,  however,  be  removed 
with  the  shaft  of  the  bone  which  it  surrounds." 

Bloodgood  makes  the  following  interesting  observation  on  the 
character  of  the  urine  in  cases  of  bone  tumors :  "  In  the  multiple  myeloma 
of  bone,  Bence-Jones  bodies  are  present.  Clinically,  this  hopeless 
disease  of  medullary  tissue  ma}^  in  a  few  instances  present  itself  as  a 
single  bone  lesion.  In  this  stage,  even  2:-ray  studies  of  other  bones 
may  fail  to  show  any  other  lesion.  If  the  urine  is  not  examined,  the 
surgeon  would  proceed  to  a  radical  operation  on  the  apparent  single 
bone  lesion  without  any  suspicion  of  its  multiple  nature.  The  medul- 
lary growth  of  the  myeloma  in  its  early  stage  expands  bone  and  resembles 


Fig.  527. — Enormous  fibrosarcoma  (Massacluisetts  General  Hospital). 

the  giant-cell  sarcoma  or  bone  cyst.  Later,  the  bone  capsule  is  de- 
stroyed. It  is  important  to  remember  that  in  some  instances  the 
benign  bone  cyst  may  be  a  multiple  lesion.  The  cases  thus  far  recorded 
have  been  associated  with  osteomalacia." 

Endothelioma  is  a  form  of  tumor  whose  true  character  has  been  only 
recently  determined.  It  is  made  up  of  those  endothelial  cells  which 
line  the  lymph-spaces,  and  it  occurs  most  often  in  the  skin,  especially 
in  the  parotid  region,  in  the  genital  glands,  in  the  bones,  the  lymph- 
nodes,  and  the  dura.  The  growths  frequently  simulate  epithehoma, 
Endotheliomata  grow  rapidly,  and  often  are  extremely  malignant, 
while  metastases  occur  early.  The  only  hope  of  a  cure  is  in  prompt 
and  most  thorough  extirpation. 


TUMORS   OF   THE    CONNECTIVE-TISSUE   TVl'E 


835 


There  are  suiuliy  other  t'oiins  of  sarcoma,  not  very  common. 
Angiosarcoma  is  a  sarcoma  arising  from  the  adventitia  of  blood- 
vessels;  thus  it  differs  from  the  endothelioma,  which  springs  from  the 


"^*. 


■*<2i-s*' 


Fig.   528. — Mixed  tumor  of  the  parotid  gland  (Massachusetts  General  Hospital). 

lining  of  the  lymph-spaces.      Angiosarcoma  is  astonishingly  vascular, 
and  on  section  is  found  often  to  be  the  seat  of  numerous  hemorrhages 


Fig.  529. — Sarcoma  of  humerus,  round-cell.     Two  months'  duration  (Coley). 


which  take  place  into  its  own  structure.  Often,  therefore,  it  is  deeply 
pigmented.  A  subvariety  of  angiosarcoma  is  the  perithdiovia,  which 
grows  especially  in  the  bones,  the  kidneys,  and  the  skin.     Perithelioma 


836 


MINOR   SURGERY — DISEASES   OF   STRUCTURE 


arises  in  the  perithelia!  cells  between  the  capillaries  and  the  peri- 
vascular lymph-spaces.  Both  of  these  forms  of  sarcoma — angiosarcoma 
and  perithelioma — are  extremely  malignant  and  difficult  of  extiipation. 
AVe  apply  the  term  cylindroma  to  a  tumor  of  the  angiosarcoma  type, 
in  which  hyaline  changes  have  occurred,  so  that  the  cylindric  masses 
of  altered  cells  appear  along  the  course  of  the  vessels. 

Certain  sarcomata  take  on  a  deeply  pigmented  appearance  and 
are  known  as  melanosarcomata.  These  tumors  are  not  to  be  con- 
founded with  the  pigmented  angiosarcomata,  though,  indeed,  they  are 
equally  or  more  malignant.  Melanosarcomata  appear  uniformly  and 
deeply  stained,  the  staining  being  due  to  a  deposition  of  blackish  pig- 
ment both  in  the  cells  and  in  the  intercellular  substances.  When 
removed,   these   tumors    (known    commonl}^  as  melanomata)    almost 


CUr'    tr         _ 

Fig.  530. — Osteosarcoma  of  the  humerus  (Massachusetts  General  Hospital). 

invariably  recur.  We  must  observe  that  the  term  mdanoma  is  confined 
almost  invariably  to  tumors  of  the  sarcoma  type.  Epithelial  tumors 
rarely,  if  ever,  become  melanotic. 

In  regard  to  all  sarcomata  the  reader  should  remember  that,  although 
they  often  seem  quite  isolated  from  the  adjacent  tissues,  and  even  to 
be  surrounded  by  a  sort  of  capsule,  nevertheless  careful  examination 
shows  the  cells  to  have  invaded  the  surrounding  tissiies.  There  they 
proliferate  rapidly,  and  detached  foci  may  be  found  at  a  considerable 
distance  from  the  parent  tumor.  Sarcoma  has  the  power  also  of  pro- 
ducing metastatic  deposits  often  so  small  and  numerous  that  the  term 
sarcomatosis  is  used  to  describe  the  condition.  The  metastases  of  sar- 
coma, however,  occur  later  in  the  course  of  the  disease  than  do  the 
metastases  of  carcinoma,  so  that  a  local  return  of  sarcoma  may  take 
place  several  times  after  operation  before  generalization  of  the  growth 
occurs. 


TUMORS   OF  THE   CONNECTIVE-TISSUE  TYPE  837 

Sarcomatous  metastases  take  place  along  the  course  of  the  blood- 
vessels rather  than  of  the  lymphatics,  although  in  the  case  of  osteo- 
sarcoma the  lymph-nodes  may  become  involved. 

Early  in  its  career  sarcoma  often  is  but  slightly  malignant.  It  may 
long  appear  to  remain  stationary,  so  that  when  we  attack  it  early  we 
may  reasonably  expect  completely  to  eradicate  the  growth  in  many  cases. 

Myxoma  is  a  term  applied  to  tumors  composed  of  mucous  tissue, 
such  as  the  Whartonian  jelly  of  the  umbilical  cord.  We  must  dis- 
tinguish the  true  myxoma  from  myxomatous  degeneration.  We  find 
myxomata  as  gelatinous  polypi  in  the  nose  and  in  the  external  auditory 
canal;  as  sessile  tumors  hanging  from  the  skin  of  the  perineum  and 
labia;  and  as  neuromyxomata,  involving  the  nerve-trunks.  All  myxo- 
mata should  be  thoroughly  extirpated  and  the  wound  cauterized, 
for  although  these  growths  are  not  properly  malignant,  they  tend  to 
recur  again  and  again,  giving  rise  to  chronic  and  long-continued  dis- 
turbances. 

A  myoma  is  a  tumor  composed  of  unstriped  muscle-fibers;  hence 
we  find  these  growths,  as  we  should  expect,  in  certain  definite  locations 
— in  the  uterus.  Fallopian  tubes,  the  vagina,  esophagus,  alimentary 
canal;  in  the  prostate,  bladder,  and  skin.  The  tumors  are  encapsulated 
commonly,  and  are  composed  of  fusiform  muscle-cells  with  rod-like 
nuclei.  Often  they  grow  as  mixed  tumors,  so  that  when  found  in 
the  uterus  especially  we  describe  them  by  the  term  fibromyoma  or  myo- 
fibroma. They  are  properly  non-malig-nant,  but  accumulating  experi- 
ence teaches  that  a  uterus  long  the  seat  of  a  myoma  may  eventually 
develop  carcinoma.  The  complete  removal  of  a  myoma  cures  the 
disease. 

Angioma  is  the  term  applied  to  tumors  composed  of  blood-vessels 
— nevus,  cavernous  angioma,  arterial  angioma,  etc.  I  have  already 
described  these  growths  elsewhere  in  the  chapters  on  Regional  Sugery, 
especially  in  Chapter  XXVII. 

By  the  term  lymphangioma  we  mean  a  tumor  composed  of  lymph- 
vessels — a  tumor  resembling  in  many  respects  an  angioma.  There  is 
the  lymphatic  nevus,  a  mass  of  lymphatics  found  sometimes  upon  the 
surface  of  the  body,  but  most  often  on  the  lip  and  tong-ue.  The  tongue 
so  affected  may  become  greatly  enlarged,  and  protrude  from  the  mouth. 
This  form  of  enlarged  tongue  is  called  a  macroglossia. 

Cavernous  lymphangioma  is  a  condition  in  which  the  lymph-vessels 
become  greatly  distended  and  sacculated. 

Lymph  cysts  are  still  more  exaggerated  forms  of  lymph-vessel  dilata- 
tion. These  cysts  are  usually  encapsulated,  and  give  rise  to  that 
peculiar  condition  I  have  already  described  (Chapter  XXVII)  under 
the  caption  Elephantiasis. 

A  word  about  the  treatment  of  the  lesser  forms  of  lymphangioma: 
formerly  they  were  removed  by  dissection,  by  electrolysis,  and  by 
injections  of  boiling  water.  Recently  we  have  found  that  the  applica- 
tion of  liquid  air,  or,  better,  carbon  dioxid  snow,  suffices  to  cure  the 
ailment,  and  that  the  resulting  scar  is  trifling. 


838  MINOR    SUKGEUY— DISEASES    OF    STFilCTrHE 

So  much,  biiolly,  for  the  connective-tissue  group. 

The  neuromata  constitute  our  fifth  group,  uud  with  the  neuromata 
I  have  iihviuly  dealt  in  Chapters  XXIV  and  XXV. 

We  must  say  a  word  further  of  glioma.  Tliis  is  a  malignant  tumor 
found  generally  in  the  brain,  rarely  in  the  spinal  cord.  It  is  extremely 
malignant;  springs  from  the  nervous  tissue;  and  appears  as  a  trans- 
lucent swelling  infiltrating  the  surrounding  tissue.  It  has  a  thin,  gel- 
atinous consistency,  and,  microscopically,  it  resembles  neuroglia.  It 
does  not  form  metastases;  it  is  extremely  vascular;  it  proves  its  malig- 
nancy by  destroying  adjacent  structures.  It  may  appear  in  the  orbit 
and  the  eye;  and  it  is  more  common  in  the  young  than  in  the  old. 
Fortunately,  glioma  is  one  of  the  rare  forms  of  nervous  tissue  tumor. 
Though  operations  for  its  relief  have  been  undertaken,  they  have  given 
no  more  than  temporary  relief. 

We  have  already  discussed  neuroma  and  plcxifor7n  neuroma  (Chapter 
XXVII). 

Malignant  neuroma  is  properly  a  sarcoma  of  the  nerve  structures 
— a  sarcoma  usually  of  the  spindle-cell  variety. 

EPITHELIAL  TUMORS 

Epithelial  tumors  constitute  our  group  six.  Like  tumors  of  the  con- 
nective-tissue group,  they  are  benign  and  malignant,  but  the  most 
benign  epithelial  tumors  (moles  and  warts)  even  may  become  malignant, 


-•*???■>    i  // 


V 


Fig.  531.— Cutaneous  horn  (Massachusetts  General  Hospital). 

as  recent  observers  have  demonstrated.  Papilloma  is  the  common 
type  of  a  non-malignant  epithelial  growth,  and  of  papilloma  there  are 
several  varieties.     Warts  I  have  already  described  in  Chapter  XXVI. 


EPITHELIAL   TUMORS 


839 


Of  the  innocent  wart,  let  us  recall  this  significant  fact :  when  of  long 
standinf;-,  and  in  an  individual  no  longer  young,  it  may  develop  into  a 
truly  malignant  epillu^lioma;  for  the  benign  wart,  which  springs  up- 
ward and  grows  without  damage  to  surrounding  structures,  later  may 
progress  downward,  may  sink  deeply  into  adjacent  tissue,  and  may 
become  a  true  cancer.  For  this  reason  we  should  not  hesitate  radically 
to  remove  warts  and  "moles"  of  long  standing. 

Villous  papilloma  grows  in  the  bladder  and  in  the  pelvis  of  the 
kidney.  This  tumor  springs  from  the  mucosa.  It  has  long,  fern- 
like villi,  and  disturbs  the  patient  by  hemorrhage  only  or  by  choking 
the  urinary  channels.  Villous  papilloma  may  arise  from  the  choroid 
plexuses  of  the  lateral  ventricles  of  the  brain.  Villous  papillomata, 
when  accessible,  should  be  removed,  lest  they  become  malignant. 


Cutaneous  horn  (Bland-Sutton). 


There  are  intracystic  villous  growths  and  there  are  ovarian  papil- 
lomata. The  ovarian  papilloma  may  be  maHgnant,  for  if  broken  up  at 
the  time  of  operation,  the  particles  seem  to  attach  themselves  to  the 
peritoneal  surfaces,  and  there  to  grow  luxuriantly. 

Cutaneous  horns  are  epithelial  growths.  Bland-Sutton  has  a  long 
and  interesting  chapter  on  cutaneous  horns.  He  describes  sebaceous 
horns,  warty  horns,  horns  growing  from  cicatrices,  and  7iail  horns.  These 
are  all  benign  growths  and  should  be  thoroughly  removed. 

We  have  already  described  in  their  appropriate  chapters  various 
forms  of  epithelial  disease  of  the  thyroid  gland  {goiter)  and  of  the  ovaries, 
especially  that  form  of  glandular  cystoma,  the  multilocular  cyst,  with 
numerous  cavities  filled  with  fluid,  and  containing  a  small  number  of 


840 


MINOR  SURGERY — DISEASES   OF   STRUCTURE 


epithelial  cells,  while  the  cyst-wall  may  contain  tubular,  gland-like 
structures  reaching  into  the  surrounding  connective  tissue;  and  the 
papillary  cystoma,  a  cyst  presenting  projecting  papillomatous  growths 
into  the  cyst  cavities — growths  covered  by  cylindric  epithelium;  and 
we  recall  that  the  glandular  and  papillary  types  frequently  are  blended. 
An  adenoma  (also  Jlbro-adenoma)  is  a  tumor  whose  type  is  the 
normal  secreting  gland.  Now  the  adenoma  differs  from  the  gland  in 
that  it  is  an  abnormal  outgrowth;  and  further  in  that  it  has  not  the 
power  of  secretion  peculiar  to  the  analogous  gland  which  it  represents. 
Adenomata  are  circumscribed  tumors  found  most  commonly  in  the 
breast,  the  parotid,  the  thyroid,  the  liver,  and  the  mucous  lining  of  the 
bowels  and  uterus.  Adenomata  may  be  single  or  multiple;  they  may 
be  small  or  very  large;  they  do  not  involve  the  lymphatics  or  give  rise 
to  metastases.  They  are  easily  confounded  with  cancer,  into  which 
they  may  readily  degenerate;  or  the  two  may  coexist.  A  cancer  of  the 
adenomatous  type  is  commonly  referred  to  as  an  adenocarcinoma. 


Fig.  5.3.3. — Epithelial  odontoma  fredra\\n  from  Bland-Sutton). 

Fihro-adenoma  is  a  small  hard  tumor  found  commonly  in  the  breast 
of  young  women,  encapsulated,  usually  superficial,  movable,  and  often 
multiple. 

Of  recent  years  it  has  become  the  fashion,  following  the  lead  of 
Bland-Sutton,  to  classify  separately  tumor  diseases  of  the  teeth — 
odontomata.  More  properly,  perhaps,  these  timiors  should  be  classed 
either  with  the  connective-tissue  or  with  epithelial  groups. 

"An  odontoma  is  a  tumor  composed  of  dental  tissues  in  varying 
proportions  and  different  degrees  of  development,  arising  from  teeth- 
germs,  or  teeth  still  in  process  of  growth"  (Bland-Sutton).  We  must 
recognize  three  distinct  elements  in  the  developing  tooth — the  enamel- 
organ;  the  papilla,  from  which  the  dentin  is  derived;  and  the  tooth- 
sac,  which  furnishes  the  cementum.  Early  in  its  development  the 
various  tissues  of  the  tooth  are  soft  and  enveloped  in  a  sac  which  lies 
buried  along  the  borders  of  the  jaws. 

Accordingly,  we  have  epithelial  odontomata,  which  have  a  capsule, 
and  appear  usually  as  a  series  of  cysts  containing  mucoid  fluid,  while 


EPITHELIAL  TUMORS 


841 


the  growing  portions  have  a  red  tint,  not  unlike  sarcoma.     Epithelial 
odontomata  are  scon  most  commonly  about  the  twentieth  year  of  life. 

Follicular  odontomata  are  those  tumors  which  have  commonly  been 
called  '' dentigerous  cysts."  Unlike  the  epithelial  odontomata,  these 
growths  ai'ise  in  connection  with  the  prmanent  teeth,  especially  the 
molars.  They  may  reach  a  considerable  size  and  cause  a  marked 
deformity.  The  tumor  is  made  up  of  a  wall — the  expanded  tooth- 
follicle— and  of  a  cavity  containing  viscid  fluid,  as  well  as  some  portion 
of  an  imperfectly  developed  tooth. 
The  cyst-wall  always  contains  calcar- 
eous material.  These  tumors  rarely 
suppurate. 

Fibrous  odontomata  also  arise  in 
connection  with  developing  teeth. 
They  are  formed  of  dense  connective 
tissue,  and  appear  as  tumors  with  a 
firm  outer  wall  and  a  loose  inner 
texture — blending  at  the  root  of  the 
tooth  with  the  dental  papilla.  The 
developing  tooth  thus  becomes  in- 
closed within  the  tumor  capsule  be- 
fore it  protrudes  from  the  gum.  These  tumors  are  more  common  in 
cattle  than  in  man.     The  growths  often  are  multiple. 

A  cementoma  is  a  fibrous  jaw  tumor  whose  capsule  has  calcified.  It 
springs  from  a  developing  tooth  which  becomes  embedded  in  a  mass  of 
dental  cement.     These  tumors  are  most  common  in  horses. 

Compound  follicular  odontomata  contain  a  mimber  of  masses  of 
cementum  resembling  small  teeth,  or  they  may  amount  even  to  well- 


Fig.  534. — Follicular  odontoma 
(Bland-Sutton). 


Fig.  535. — Composite  odontoma  (Bland-Sutton). 

developed  but  misshapen  teeth,  composed  of  all  three  dental  elements. 
In  these  compound  follicular  odontomata  many  teeth  are  found. 
Human  beings  are  frequently  subject  to  this  disease. 

Radicular  odontomata  spring  from  the  dentin  and  cementum  after 
the  crown  of  the  tooth  has  been  formed,  and  while  the  roots  are  still 
developing.     These  growths  are  more  common  in  animals  than  in  man. 


842  MINOR    SURGERY — DISEASES   OF   STRUCTURE 

Composite  odontomata  are  hard  tumors  composed  of  enamel,  dentin, 
and  cementum.  Thus  they  contain  all  the  elements  of  the  tooth-germ, 
but  they  bear  little  resemblance  to  normal  teeth.  They  are  found  in 
man  only. 

These  tumors  of  the  jaws  seem  to  have  attracted  the  attention  of 
the  older  rather  than  of  the  more  recent  writers,  yet  present  experience 
shows  us  that  they  are  quite  common,  especially  in  young  persons. 
An  extremely  significant  fact  is  that  frcciuently  odontomata  are  mis- 
taken for  sarcomata,  so  that  we  learn  this  lesson:  all  tumors  of  the  jaws 
which  are  not  obviously  malignant  should  be  explored  carefully  for  the 
detection  of  odontomata  before  a  resection  of  the  jaw  is  done.  The 
odontomata  can  always  be  satisfactorily  treated  by  a  complete  excision, 
which  should  leave  little  deformity,  and  should  result  in  the  restoration 
of  a  normal  and  useful  jaw. 

CANCER 

Cancer  is  a  term  of  wide-reaching  significance.  In  ancient  times 
writers  seem  to  have  used  the  word  to  describe  all  manner  of  malignant 
growths;  and  in  our  own  day,  clinical  writers  in  general  terms  have 
applied  the  word  "  cancer"  to  tumors  structurally  as  different  as  sarcoma 
and  malignant  epithelioma.  Commonly,  however,  we  mean  by  cancer 
carcinoma,^  "a  tumor  composed  chiefly  of  epithelial  cells,  differing 
more  or  less  in  their  type  and  arrangement  from  the  usual  epithelial 
structures,  and  having  a  tendency  to  an  unlimited  growth.  These 
cells  grow  into  the  surrounding  connective  tissue,  which  is  thereby 
stimulated  to  increased  development.  Carcinoma  is  composed,  there- 
fore, of  two  distinct  structures — epithelial  cells  and  the  vascular  stroma" 
(Warren) . 

Cancer  is  a  disease  of  paramount  importance  because,  when  untreated, 
it  is  almost  invariably  fatal,  though  recent  studies  in  immunity  are  lead- 
ing us  to  believe  that  the  occasional  spontaneous  cure  of  cancer  is 
credible.  Cancer  is  marked  by  its  insidious  onset;  by  its  painlessness 
in  its  early  stages;  l)y  its  progressive  and  irresistible  destructiveness; 
by  its  mysterious  dissemination  (see  the  Theory  of  Handley  in  Chapter 
XIX);  by  its  involvement  of  the  lymph-nodes;  by  its  metastases  in 
remote  parts;  by  the  hopelessness,  misery,  and  pain  it  produces  when 
fully  developed;  and  by  the  extreme  difficulty  of  its  extirpation.  I 
shall  have  occasion  shortly  to  point  out  our  present  hope  for  its  cure. 

Carcinoma  and  epithelioma  are  terms  which  should  be  obvious  enough, 
yet  modem  writers  still  employ  the  words  in  a  somewhat  confusing  sense. 
For  example,  Roswell  Park  says  of  carcinoma  that  it  is  a  tumor  springing 
from  preexisting  gland  tissue;  and  of  epithelioma,  that  it  is  common 
especially  where  there  is  transition  from  one  kind  of  epithelium  to 
another ;   while  Bland-Sutton  -  does  not  use  the  terai  epithelioma  at  all. 

1  Greek,  KapKivoc,  a  crab,  a  term,  according  to  Uelsus,  applied  to  malignant 
growths  on  account  of  a  crab-like  appearance,  due  to  the  great  enlargement  of  super- 
ficial vessels  centering  about  the  tumor. 

2  Keen's-Surgerj',  vol.  i. 


CANCER 


843 


I  prefer  to  use  the  Avonl  <  piiluiiotiKi  iind  carcinoma  as  interchanguble. 
By  epithelioma  Ave  uiulerstiiud  a  nuilignant  tumor  comi3osed  chiefly  of 
epithehal  cells,  and  that  definition  applies  also  to  carcinoma,  a  disease 
\vhich  is  not  limited  by  any  means  to  gland  tissues.  This  confusion 
of  terms,  as  Warren  reminds  us,  is  due  to  the  fact  that  in  past  times 
the  word  epithelium  was  used  to  describe  cancers  consisting  of  pavement 
epithelium. 

Carcinoma  (or  epithelioma),  accordingly,  has  various  subdivisions, 
all  of  them  differing  from  the  non-malignant  papilloma  in  that  they  are 
not  limited  by  a  basement  membrane,  but  pass  beyond  it  into  the 


Fio-    536 —Epithelial  pearl  formation  in  squamous  epithelioma    (middle  power) 
^'  ■  (Park). 

underlying  connective  tissue.  Wherever  epithelial  structures  exist, 
there  carcinomata  may  develop,  and  our  opportunities  for  observing 
the  appearances  of  cancer  depend  upon  the  cancer  site.  A  cancer^  of 
the  tongue,  the  lip,  or  the  penis  is  instantly  obvious,  and  may  be  studied 
from  the  outset.  Cancer  of  the  stomach,  of  the  intestine,  or  of  the 
uterus  is  long  latent,  and  usually  comes  into  the  field  of  observation 
when  the  disease  is  well  advanced  only.  Incidentally  we  see  that  for 
these  reasons  the  early  observed  superficial  cancers  frequently  are 
cured,    while    internal  cancers,    observed    late,    are    cured   far   more 

rarely.  ^^ 

Superficial    cancer — squamous-cell    cancer— apipeavs   usually    as      a 


844 


MINOR   SURGERY — DISEASES   OF   STRUCTURE 


wart-like  growth  or  nodule,  which  quickly  becomes  an  ulcer  with 
elevated  edges,  the  ulceration  being  due  to  the  necrosis  of  the  cells 
farthest  from  the  periphery;  or,  again,  the  disease  may  start  as  an 
ulcerated  fissure. — ulceration  and  infiltration  keeping  pace, — in  which 
case  there  is  a  sharply  defined  ulcer  with  undermined  edges.  A  third 
variety  of  squamous-cell  cancer  often  seen  upon  the  lips  comprises  a 
projecting  mass,  with  a  more  or  less  homy  surface.  In  nearly  all  of 
these,  however,  characteristic  cell-nests,  with  their  onion-like  arrange- 
ment of  cells,  willj)e  found"  (Roswell  Park).  Such  is  the  superficial 
epithelioma. 


Fig.  537. — Metastasis  of  squamous  epithelioma  in  a  lymph-node. 

(middle  power)  (Park). 


Pearl  formation 


All  observers  dwell  upon  the  invariable  lymph-node  involvements 
which  accompany  cancer.  The  lymph-nodes  in  cancer  are  invaded 
early.  Sometimes  our  first  intimation  of  malignant  disease  comes 
from  finding  the  enlarging  lymph-nodes;  later  we  may  discover  the 
original  cancer  focus.  I  have  referred  more  than  once  to  Handley's 
ingenious  theory  of  cancer  dissemination,  and  have  described  it  in 
Chapter  XIX.  Moreover,  our  studies  of  cancer  in  the  chapters  on 
Regional  Surge r}^  render  needless  further  and  special  description  of 
cancer  here.  I  refer  the  reader  e.specially  to  Chapters  XX  and  XXI 
for  descriptions  of  rodent  ulcer,  that  most  shocking,  chronic,  and  dis- 
figuring of  diseases;  and  of  cancer  of  the  tongue,  lip,  and  jaws. 

The  varieties  of  cancer  referred  to  in  the  preceding  paragraphs  are 


CAXCER 


845 


commonly  known  as  sqitamous-cell  cancer — cancer  which  makes  its 
appearance  on  any  surface  covered  with  stratified  epithehum.  It  may 
be  worth  while  to  recapitulate  some  of  the  important  locations  where 
such  cancers  are  found:  on  the  lips,  tongue,  cheek,  vulva,  anus,  scrotum, 
gians  penis,  conjunctiva,  pinna,  urethra,  about  scars  and  chronic 
ulcers,  and  on  the  neck  of  the  uteiiis. 

Of  late  years  we  have  heard  much  of  precancerous  conditions,  and 
Bland-Sutton  and  other  writers  have  dealt"  especially  upon  leukoplakia 
of  the  tongue  and  buccal  mucosa  as  a  condition  precedent  to  cancer. 
Doubtless  such  precancerous  conditions  are  extremely  common,  if  only 
surgeons  might  observe  them  and  recognize  their  significance. 

Gland  cancer  is  important  ec[ually  with  cancer  of  the  squamous-cell 
variety.  Gland  cancer  resembles  the  gland  tissue  from  which  it  springs, 
except  that  the  stiiictural  similarity  is  incomplete.  The  epithelial  cells 
collect  in  irregular  clusters,  fill  the  acini,  obstiiict  the  ducts,  and  invade 
the  surrounding  tissues.  These  cancers  may  arise  from  any  secreting 
gland;  they  spread  rapidly.  Distant  metastases  appear  early,  and  it 
is  an  extremely  interesting  characteristic  of  these  metastases  that  they 
reproduce  almost  perfectly  the  type  of  primary  tumor  whence  they  spring. 
For  this  reason  the  study  of  such  a  metastatic  growth  frequently  gives 
us  definite  information  as  to  its  origin. 

The  classic  types  of  gland  cancer  are  found  in  the  breast,  and  the 
intricate  and  numerous  manifestations  of  breast  cancer  have  already 
been  described  in  detail  in  Chapter  XIX.  I  need  add  nothing  here 
to  what  I  there  stated  beyond  naming  other  organs  subject  to  this 
disease — the  salivary  glands,  liver,  kidney,  ovary,  and  testicle.  More- 
over, the  squamous  and  gland  types  of  cancer  may  overlap  and  co- 
exist . 

For  a  brief  description  of  mcdignant  chorio-epithelioma,  or  the 
deciduoma  mcdignum,  and  of  suprarencd  epithelioma — hypernephroma, 
1  refer  to  Chapters  X  and  XIII. 

The  following  tables,  taken  from  Roswell  Park's  Modern  Surger}', 
mav  assist  the  student  in  his  studv  of  tumor  diagnosis : 


TABLE   I.— DIFFERENTIATION   BET'U'EEN  BENIGN   AND   MALIGNANT 

GRO^yTHS. 


Bexigx  Gro"r-ths. 

Common  at  all  ages. 

Tjsually  slow  in  gro-^^th. 

No  evidences  of  infiltration  or  dissemin- 
ation. 

Are  often  encapsulated,  nearly  always 
circumscribed. 

Rarely  adherent  unless  inflamed. 

Rarely  ulcerate. 

Overlj-ing  tissue  not  retracted. 
No  lymphatic  involvement  when  not  in- 
flamed. 
No  leukocj'tosis. 
EUmination  of  urea  imaffected. 


Malignant  Growths 

Rare  in  early  life. 

L^sually  rapid  in  growth. 

Infiltration  in  all  cases,  dissemination 
in  many. 

Never  encapsulated,  seldom  circimi- 
scribed. 

Always  adherent. 

Often  ulcerated — nearly  always  when 
surface  is  involved. 

Overlying  tissue  nearly  always  retracted. 

Lymphatic  involvement  an  almost  con- 
stant feature. 

Leukocj"tosis  often  marked. 

Deficient  elimination  of  urea  (?). 


846 


MINOR    SURGERY — DISEASES   OF   STRUCTURE 


TABLE  II.— DIAGNOSIS  BETWEEN  SARCOMA  AND  CARCINOMA. 


Sahcoma. 

Occurs  at  any  age. 

Dissciniuutcs      by      tlie      bkioil-vcssels 

(^veins). 
Arises  from  inesoblastic  structures. 

Distant  metastases  arc  more  common. 
Contains      blood-channels     rather      than 

complete  blood-vessels. 
Less  prone  to  ulceration. 
Involvement  of  adjacent  lympliatics  not 

common. 
Secontlary     changes    and    degenerations 

are  more  common. 
Sugar  present  in  the  blood . 


Carcinoma. 

Rare  before  thirtieth  year  of  life. 
Disseminations  by  the  lymphatics. 

Arises   from   glandular    (cijithelial)    tis- 
sues. 
Less  so. 
Contains  vessels  of  normal  type. 

More  so. 

Almost  invariably  atljacent  lymphatics 
are  involved. 

Degenerations  not  common;  other  sec- 
ondary changes  rare. 

Peptone  present  in  the  blood . 


TABLE  III.— DIAGNOSIS    BETWEEN  EPITHELIOMA   AND   TUBERCULO- 
SIS (LUPUS). 


Epithelioma. 

Preceded  usually  by  continued  irritation 

or  warty  growths. 
Diathesis  plays  no  known  part. 


Rarely  multiple. 

Area  of  thickening  ahead  of  ulceration. 

Ulceration  advancing  from  a  central 
focus. 

Border  usually  raised  and  everted,  regu- 
lar in  outline. 

Often  assumes  fungoid  type. 

Base  may  be  deeply  excavated. 

L^sually  painful. 

Bleeds  easily. 

Never  tends  to  cicatrize. 

Most  rare  in  the  young. 
Discharge  is  verj'  offensive. 
Lymphatic  in\olvement  nearly  always. 


Tuberculosis  (Lupus). 

Irritation  plays  no  figure.  Preceded 
usually  by  nodules. 

Diathesis    evident.  Coincident    evi- 

dences of  tuberculous  disease  else- 
where. 

Often  multiple. 

Extension  of  ulceration  not  preceded  by 
thickening. 

Various  foci,  which  may  coalesce. 

Border  abrupt,  eaten,  irregular,  thick- 
ened, firm,  often  inverted,  irregular 
in  outline. 

Never  fungoid. 

Base  nearly  level  with  surface. 

Seldom  painful. 

Seldom  bleeds. 

As  marginal  ulceration  proceeds  there 
is  often  cicatrization  at  center. 

Common  in  the  young. 

Discharge  rarely  offensive. 

Rarely. 


After  all  is  said,  what  shall  we  tell  the  student  and  the  general  prac- 
titioner regarding  the  surgeon's  attitude  toward  the  cancer  problem, 
and  the  question  of  its  cure?  This  is  no  place  in  which  to  discuss  the 
great  question  of  the  causation  of  cancer,  as  I  have  already  stated. 
Doubtless  should  investigation  prove  to  us  that  cancer  is  of  parasitic 
origin,  the  inevitable  next  step  of  finding  its  antidote  would  follow. 
To-day,  however,  we  are  faced  with  the  problem  of  present  treatment, 
and  surgeons  are  finding  that  the  careful  and  extensive  modem  opera- 
tions are  lowering  cancer  mortality.  I  have  already  said  that  super- 
ficial cancer  may  and  should  be  attacked  early.  As  Crile  remarks  in 
his  illuminating  paper,*  we  should  not  wait  for  the  disease  to  develop 

*  Oration  in  surgerj''  before  the  American  ]\Iedical  Association,  published  in  the 
Jour.  Amer.  Med.  Assoc,  June  6,  1908,  p.  1883;  also.  Jour.  Med.  Research,  1908, 
xlvii,  385. 


CANCER 


847 


itself  in  order  to  establish  a  diagnosis;  we  should  remove  the  disease 
as  soon  as  it  is  seen,  and  then  establish  our  diagnosis.  In  several  fore- 
going chapters  of  this  book  I  have  already  described  the  various  and 
elaborate  methods  of  operation  now  in  vogue. 

Our  endeavor  must  be,  therefore,  to  arrive  at  an  early  diagnosis. 
How  shall  we  do  this  in  the  case  of  those  cancers  which  are  hidden  from 
view?  Says  Crile :  "  I  have  often  thought  that,  pending  a  more  general 
enlightenment,  it  would  be  a  great  boon  to  mankind  if  the  words  '  glan- 
dular enlargement  and  cachexia,'  as  denoting  symptoms  of  cancer,  were 
stricken  from  every  text-book  of  medicine.  These  are  terminal  symp- 
toms, and  indicate  that  the  surgical  opportunit}'  is  forever  lost.  Were 
the  result  not  so  tragic,  such  professional  simple-mindedness  would  be 
ludicrous."  Through  his  studies  in  hemolysis,  Crile  has  arrived  at  an 
extremely  interesting  and  probably  valuable  hypothesis  which  he  is 
applying' to  the  diagnosis  of  early  cancer.  To  quote:  "The  blood-serum 
of  a  cancer  patient  may  hemolyze  normal  corpuscles,  but  normal  blood- 
serum  usually  does  not  hemolyze  the  red  corpuscles  of  a  cancer  patient. 
In  some  patients— thus  far  only  those  with  inoperable  cancer— there 
was  reverse  hemolysis.  The  cancer  corpuscles  were  hemolyzed  by 
normal  serum.  In  some  cases  there  was  no  reaction.  If  this  reaction 
is  to  be  of  diagnostic  value,  then  it  must  occur  in  cancer  cases  only  or  m 
diseases  not  readily  confused  with  cancer."  In  other  words,  we  have 
in  the  hemolysis  blood-test  a  promising  method  for  the  determination 
of  early  internal  cancer;  and  Crile's  statistics,  already  considerable, 
show  this  test  to  be  fairly  reliable. 

Crile  makes  this  further  intensely  interesting  statement:  '^The 
work  of  Gaylord  and  Clowes,  Beebe  and  Ewing,  Ehrlich,  Loeb,  and 
others,  demonstrating  a  not  infrequent  immunity  against  cancer,  was 
utilized  by  Beebe  and  myself  in  an  attempt  to  cure  transplanted  sarcoma 
in  dogs  by  maximum  bleeding  of  the  'tumor  dog'  and  heavy  over- 
transfusion  from  an  immune  dog.  By  this  method  we  have  cured  of 
sarcoma  nine  out  of  eleven  dogs,  some  of  which  were  cachectic  and  had 
metastases.  The  cured  animals  in  turn  became  immune  and  were 
successfullv  emploved  for  curing  and  immunizing  other  dogs.  .  _  .  . 
Arguing  from  this  work  and  from  the  fact  that  among  the  lower  anmials 
certain^'ones  are  naturally  immune,  we  have  transfused  normal  blood 
into  six  human  subjects  having  sarcoma,  their  tumors  havmg  been 
removed  previously  to  transfusion.  Sixteen  months  have  now  elapsed 
since  the  first  case  was  so  treated  (without  recurrence) .  .  .  .  _  Should 
these  patients  be  cured  (after  three  or  more  years)  and  become  nnmune, 
it  is  likelv  that  they  may  be  available  for  curing  others,  so  that  eventually 
a  group  of  immunes  may  be  established."  Crile  goes  on  to  say,  prop- 
erlv  and  guardedly,  that  ''the  whole  matter  of  immunizmg  agamst 
sarcoma  is  at  this  time  wholly  experimental,  and  my  statements  are 
presented  with  that  understanding." 

Besides  the  knife,  various  measures  have  been  and  are  to-day 
emploved  for  the  cure  of  malignant  disease.  The  a--ray  and  radium 
have  an  apparent  curative  effect  in  certain  superficial  cancers.     In 


848  MINOR   SURGERY — DISEASES   OF    STRUCTURE 

doubtful  cases  after  operation  on  deep-seated  tumors  the  skin-flaps 
may  be  retracted  and  the  x-rays  applied  daily  and  directly  to  the  depths 
of  the  wound. 

Coley's  well-known  treatment  with  the  mixed  toxins  of  erysipelas 
and  the  Bacillus  prodigiosus  has  had  promise,  and  the  method  has 
still  a  vogue.     The  best  results  have  been  obtained  by  Coley  himself. 

Numerous  other  measures  have  been  advocated  and  are  still  advo- 
cated, such  as  ultraviolet  rays,  pyoktannin,  formalin,  etc.^  One  of  the 
most  interesting  of  these  measures  is  that  of  Beatson,  of  Glasgow,  who 
suggests  the  benefit  of  the  removal  of  the  ovaries  in  hopeless  cases  of 
mammary  cancer.  He  has  reported  instances  of  apparent  cure.  The 
so-called  ''trypsin  treatment"  of  malignant  tumors  was  promulgated 
by  Beard,  of  Edinburgh,  and  still  finds  its  advocates,  who  assert  that 
although  the  record  of  cases  is  far  from  perfect,  still  the  reasoning 
on  which  the  treatment  is  founded  should  prove  correct  when  worked 
out  in  more  detail. 

In  brief  and  unsatisfactory  detail  such  is  the  problem  of  the  treat- 
ment of  malignant  tumors  as  we  see  it  to-day.  Save  for  the  campaign 
against  tuberculosis,  no  campaign  in  all  medicine  is  being  more  actively 
pushed  than  this  cancer  campaign;  and  we  have  strong  reason  to 
believe  that  within  the  years  immediately  coming  we  shall  arrive  at  a 
clear  understanding  of  the  nature  of  malignant  disease,  and  shall  obtain 
a  rational,  safe,  and  sound  remedy. 

1  Skene  Keith  and  George  E.  Keith  report  great  relief  from  pain  and  marked 
improvement  in  the  general  condition  of  the  patients  from  the  hypodermic  use  of  a 
compound  of  iron,  sodium,  and  iodin.  To  quote:  "  This  strong  standard  injection 
consists  of  a  solution  of  iodipin  in  oil,  arseniate  of  iron,  cacodylate  of  iron,  and  cin- 
namate  of  sodium..  The  iodipin  is  a  25  per  cent,  solution  in  oil.  The  arseniate  of 
iron  contains  |  grain  of  iron  and  j^  grain  of  arsenious  anhydrid  in  1  cc.  The  caco- 
dylate of  iron  contains  3  grains  of  iron  in  1  cc.  The  cinnamate  of  sodium  is  a  satur- 
ated solution  containing  li  grains  to  the  cubic  centimeter.  .  .  .  The  average 
proportions  of  the  emulsion  which  we  have  used  most  are  as  follows:  1  dram  of  the 
iodipin  and  20  minims  each  of  the  other  three.  .  .  .  The  dose  varies  also. 
Some  patients  appear  to  do  well  with  5  cc.  of  the  emulsion  given  everj"  second  day 
or  even  every  day,  while  it  seems  to  be  advisable  with  others  not  to  give  more  than 
2  or  3  cc." — Cancer,  Relief  of  Pain  and  Possible  Cure,  p.  33. 

Almost  equally  useful  apparently  is  the  treatment  advocated  for  cases  of  in- 
operable cancer  by  G.  W.  Gay,  of  Boston,  a  treatment  I  have  used  myself  vritb  .satis- 
faction: Give  5  drops  of  the  compound  solution  of  iodin  three  times  a  day  and  in- 
crease the  dose  rapidly  until,  by  the  end  of  a  month,  the  patient  is  receiving  60  to  100 
drops  in  the  twenty-four  hours.  Frequently,  by  the  use  of  this  dnig,  pain  is  allayed, 
the  rapidity  of  the  tumor's  growth  seems  to  be  checked,  and  life  is  prolonged.  It 
may  be  necessary  to  supplement  the  iodin  by  small  doses  of  the  tincture  of  opiimi 
given  by  rectum  and  repeated  at  short  inter\'als — 3  or  4  drops  every  three  hours, 
the  surgeon  being  careful  not  to  .saturate  the  patient  with  the  drug. 


CHAPTER  XXIX 
FRACTURES   AND   DISLOCATIONS 

Fractures 

A  FRACTURED  bone  is  a  broken  bone.  I  know  of  no  phrase  or  com- 
bination of  terms  that  sums  it  more  accurately.  In  spite  of  the  a:-ray, 
the  treatment  of  fractures  does  not  form  a  popular  division  of  surgical 
practice.  .  Most  surgeons  would  shun  fractures  if  the}'  could.  Fractures 
comprise  a  department  of  surgery  distinct  and  unique.  Moreover,  in  a 
book  of  this  character,  it  is  impossible  adequately  to  deal  with  the  great 
subject  of  fractures.  For  proper  details  the  surgeon  should  consult  the 
well-knoMTi  books  of  Hamilton,  Stimson,  or  Scudder.  It  will  be  useful, 
however,  for  the  student  to  gain  some  general  idea  of  fractures  and  their 
treatment  from  such  a  brief  essay  as  I  can  address  to  him  here. 

In  the  first  place,  let  us  consider  some  general  topics  in  comiection 
with  fractures,  and  then  briefly  review  special  fractures  and  their  treat- 
ment . 

Commonl}-,   fractures   are  described  in  various  terms.     To   quote 
Eisendrath,^  fractures  are  classified: 
I.  i^ccording  to  their  degree. 
II.  According  to  the  direction  of  the  line  of  fracture. 

III.  According  to  their  location. 

IV.  According  to  their  etiology. 

V.  According  to  their  relation  to  the  overh'ing  skin. 
VI.  According  to  the  number  of  fragments. 
VII.  According  to  whether  or  not  they  are  complicated. 
This  classification  is  good,  and  certainly  expresses  recognized  con- 
ditions. 

I.  Fractures  are  complete  or  incomplete  and  we  use  also  the  terms 
green-stick  and  subperiosteal. 

II.  Fractures  are  transverse  or  oblique. 

III.  Fractures  are  epiphyseal  when  the  epiphyses,  commonly  in  young 
persons,  are  separatecl;  while  the  fracture  remote  from  the  epiphysis 
is  spoken  of  as  a  fracture  of  the  shaft.  We  speak  of  joint  fractures  also, 
meaning  fractures  involving  the  joints  adjacent  to  the  break. 

TV.  "We  describe  a  fracture  as  direct  and  indirect  also — referring  to 
the  manner  in  which  it  was  received.  A  direct  fracture  is  one  caused 
by  a  crushing  force  applied  to  the  seat  of  fracture.  An  indirect  frac- 
ture is  due  to  muscular  violence,  straining  the  bone  until  it  breaks. 

1  Daniel  N.  Eisendrath,  Fractures,  Keen's  Surgerj',  vol.  ii. 
54  849 


850 


MINOR    SURGEHY — DISEASES    OF    STUUCTLRE 


V.  Perhaps  the  most  important  division  of  this  classification  is  that 
which  separates  fractures  into  sinij)lc  fractures  and  conijxmnd  fractures. 
A  simple  fracture  is  one  in  which  there  is  no  communication  between 
the  broken  bone  and  the  outer  air.  A  compound  fracture  is  one  in 
which  there  is  a  wound  leading  to  the  fracture  through  the  skin  and 
soft  parts.  Of  recent  years  many  writers,  following  the  phrasing  of 
Scudder,  have  substituted  the  terms  dosed  and  open  fractures  for  simple 
and  compound  fractures. 

VI.  In  case  the  bone  is  splintered  into  three  or  more  fragments,  we 
use  the  term  comminuted  fracture.     The  term  multiple  implies  a  some- 


4. 


5. 


6. 


Fig.  538. — Various  forms  of  lines  of  fracture:  1,  Complete  transverse;  2,  longitudinal; 
3,  oblique;  4,  spiral;   5,  incomplete  or  green-stick;  6,  subperiosteal  (Eisendratli). 

what  different  condition,  and  signifies  that  one   or    more  bones  are 
broken  at  several  points. 

VII.  When  a  fracture  is  but  a  part  of  the  injury  received,  that  is, 
when  soft  parts  and  organs  as  well  as  bones  are  damaged,  we  employ 
the  term  complicated  fracture,  though  this  is,  perhaps,  a  fanciful  and 
needless  classification. 


GENERAL   CONSIDERATIONS 

Certain  considerations  recently  have  become  prominent  in  the  discus- 
sion of  all  fractures,  considerations  which  are  more  interesting  perhaps 
to  the  general  surgeon  than  are  questions  of  the  diagnosis  and  treat- 
ment of  the  average  fracture.  We  are  discussing  and  questioning  the 
inevitable  value  of  the  rc-ray.  W^e  are  considering  the  more  frequent 
treatment  of  fractures  by  opening  down  upon  and  wiring  or  othenvise 
fixing  the  fragments  beneath  the  skin.  We  are  devising  methods  of 
treating  the  old  deformities  which  sometimes  result  from  faulty  union 
of  fractures;  while  one  of  the  most  important  of  recent  discussions 
deals  with  the  treatment  of  delayed  union  and  especially  of  the  non- 
union of  fractures. 


GENERAL   CONSIDERATIONS  851 

After  the  introduction  into  practice  of  iic-ray  examinations,  some 
fifteen  yc;irs  ngo,  it  was  felt  at  first  that  at  last  we  had  secured  a  positive 
and  unfailing  niethotl  of  reaching  the  exact  diagnosis  of  a  given  fracture. 
X-ray  pictures  were  assumed  to  be  infallible,  not  only  as  indicating  the 
position  of  the  bone  fragments,  but  as  demonstrating  surely  the  func- 
tional results  of  treatment — that  is  to  say,  the  value  of  the  limb  to  the 
patient  after  the  bone  had  healed.  Such  conceptions  of  the  use  of  the 
x-YSiy  have  been  greatly  modified.  Its  indiscriminate  employment 
has  done  harm  as  well  as  good.  It  has  led  to  the  superficial  and  care- 
less palpation  of  fractures;  it  has  induced  young  and  inexperienced 
practitioners  to  rely  entirely  upon  the  a:-ray  picture,  and  it  has  imposed 
upon  juries  the  notion  that  bones,  the  fragments  of  which  are  not 
approximated  absolutely  and  accurately,  must  be  of  faulty  function  after 
union,  and  must  show  careless  treatment.  As  a  matter  of  fact,  it  is 
rare  that  closed  fractures  can  be  absolutely  approximated,  while  it  is 
the  experience  of  surgeons  for  ages  that  imperfect  apposition  commonly 
may  coexist  with  almost  perfect  function. 

Cotton  ^  has  very  properly  stated  that  the  most  important  use  of 
the  a:-ray  is  to  determine  the  position  of  the  bone  fragments  after  the  sur- 
geon has  reduced  the  fractvire.  That  writer  would  employ  the  a- -ray  when 
convenient,  as  an  aid  in  the  determination  of  the  exact  natnre  of  the 
fracture,  bearing  in  mind  always  that  other  and  common  methods  of 
investigation  should  not  be  neglected;  but  after  the  fracture  has  been 
reduced  and  has  been  held  in  its  new  position  for  a  time  sufficient  to 
allow  the  healing  process  to  begin,  he  would  then  secure  another  x-ray 
picture.  By  the  aid  of  this  latter  picture  the  surgeon  is  able  to  deter- 
mine whether  or  not  his  treatment  is  effective,  and,  if  necessary,  he  can 
then  remedy  malposition.  After  union  is  complete  and  the  limb  is 
again  in  use,  the  rc-ray  is  of  no  value  whatever,  provided  function  is 
satisfactory.  For,  as  I  have  said,  the  perfectly  functionating  limb 
may  be  supported  by  a  bone  which  shows  a  marked  deviation  from 
the  normal. 

The  open  treatment  of  fractures  is  too  seldom  used.  In  general 
terms  it  is  true  that  a  closed  fracture,  well  approximated,  promises  a 
good  result  without  further  molestation;  but  many  fractures,  after 
reduction  has  been  attempted,  show  continued  deformity,  marked 
failure  of  apposition,  and  a  tendency  to  delayed  union.  Cotton  ques- 
tions the  frequency  of  the  interposition  of  soft  parts  as  a  cause  of  mal- 
position and  delayed  union.  My  experience  is  somewhat  different.  I 
have  seen  several  cases  of  fractured  fibula  and  ulna  in  which  interposed 
tendons  obviously  prevented  a  proper  apposition  of  the  bone  fragments. 
In  such  cases  I  advise  the  surgeon  to  cut  down  upon  the  damaged  bone, 
without  hesitation,  to  push  aside  the  soft  parts,  and  to  wire  the  frag- 
ments. Again,  in  the  case  of  a  comminuted  fracture  involving  a  joint — 
especially  the  elbow-joint — frequently  it  occurs  that  with  the  patient 
etherized,  proper  motion  of  the  joint  is  found  to  be  impossible.    The  joint 

1  F.  J.  Cotton,  Notes  on  Fractures  and  Their  Treatment,  Boston  Med.  and 
Surg.  Jour.,  July  27,  1905. 


852  MINOR   SURGERY — DISEASES   OF   STRTCTrRE 

locks.  It  can  neither  be  extended  nor  flexed  normally.  In  such  a  case 
the  surgeon  should  exphiin  the  situation  to  the  patient;  .shoukl  make 
clear  to  him  the  inipossibiHty  of  satisfactory  function  without  an 
operation,  and  the  possible  dangers  of  an  operation,  and  should  insist 
that  the  patient  himself,  or  his  friends,  if  necessary,  elect  the  course  of 
procedure. 

In  connection  with  this  matter  of  simple  and  compound,  or  closed 
and  open  fractures,  let  me  remind  the  student  that  until  the  antiseptic 
era  the  dangers  of  the  open  fracture  were  incomparably  greater  than 
the  dangers  of  the  closed  fracture.  Open  fractures  were  nearly  always 
complicated  by  suppuration,  frequently  by  bone  necrosis,  often  by 
extensive  infections,  and  commonly  by  pyemia  and  death.  It  was  a 
realization  of  this  shocking  situation  which  led  Lister  to  his  studies  in 
antisepsis.  We  still  insist  upon  the  distinction  between  compound 
and  simple  fractures,  although  the  dangers  of  the  former  have  been 
nearly  eliminated,  but  danger  does  still  exist,  especially  when  the  joints 
are  involved,  so  that  one  may  not  rashly  and  unadvisedly  transform  a 
simple  into  a  compound  fracture.  Nevertheless,  the  dangers  are  now 
slight.  In  such  cases  of  joint  injuries  as  I  have  described- — simple 
comminuted  fractures  involving  the  joints,  with  the  prospect  of  a  stiff 
joint  should  no  operation  be  done — one  finds  one's  self  confronted  with 
a  choice  of  evils.  Good  practice  in  these  days  recognizes  and  approves 
cutting  dow^n  upon  such  injuries  and  removing  or  fixing  properly  the 
bone  fragments. 

Old  deformities  resulting  from  the  malunion  of  fractures  present 
to  the  conscientious  surgeon  some  of  the  most  serious  and  difficult 
questions  which  he  can  encounter.  The  questions  involved  are  those 
of  the  propriety  of  former  treatment;  the  possible  incompetence  of  the 
surgeon  who  originally  reduced  the  fracture;  the  possibility  of  a  law 
suit  against  that  surgeon,  and  one's  own  proper  action  in  the  premises; 
with  the  uncertainty  as  to  whether  or  not  a  present  late  operation  will 
materially  improve  the  unfortunate  condition  of  the  patient.  These 
are  questions  which  cannot  be  answered  positively  and  in  general 
terms.  I  advise  the  young  practitioner,  especialh',  to  avoid  involving 
himself  without  consultation  in  one  of  these  cases.  If  two  competent 
surgeons  agree  that  a  secondary  operation  will  probably  improve  the 
patient's  condition,  then  and  then  only  should  the  attending  surgeon 
undertake  the  operation.  We  are  finding  that  a  cutting  operation 
directed  immediately  at  the  deformity  is  often  of  less  value  than  an 
osteoclasis  somewhat  remo^^ed  from  the  seat  of  damage.  It  may  be 
well,  for  example,  to  do  osteoclasis  for  ''gun-stock  elbow,"  or  supra- 
malleolar osteoclasis  for  a  twisted  ankle,  at  the  classic  point  above  the 
joint,  entirely  irrespective  of  the  seat  of  the  old  damage. 

Delayed  union  must  not  be  mistaken  for  non-uynon.  Delaj'ed 
union  is  common,  especially  in  persons  of  advanced  years,  of  tuberculous 
or  syphilitic  taint,  or  in  poor  general  health.  Such  patients  should  re- 
ceive painstaking  general  care  with  perfect  hj'gienic  surroundings, 
tonics,  and  proper  food;  while  the  underlying  systemic  derangement 


GENERAL   COXSlDERATIOXFi  853 

should  be  treated.  It  is  not  uncommon  to  find  union  of  the  long  bones, 
for  example,  the  humerus,  the  femur,  and  the  bones  of  the  forearm — 
it  is  not  uncommon  to  find  their  union  delayed  for  two,  four,  or  six 
months.  In  these  cases  our  duty  is  faithfully  and  continuousl}-  to 
inmiobilize  the  damaged  limb.  I  have  seen  union  take  place  after 
twelve  months  of  non-union. 

In  certain  rare  cases,  however,  non-union  persists,  and  it  is  often 
impossible  to  determine  why  it  persists.  The  patient  seems  to  lack 
proper  bone-forming  activities,  whatever  that  may  mean.  The  ends 
of  the  fragments  may  atrophj'  and  an  actual  false  joint — pseudarthrosis 
^may  develop.  I  have  at  this  moment  among  m}-  patients  an  active, 
sound,  and  vigorous  woman  of  thirty-five,  apparently  in  perfect 
health,  who  has  carried  for  four  years  an  ununited  fracture  of  the 
ulna,  and  that  in  spite  of  numerous  operations  for  its  repair.  Happily 
these  cases  are  extremely  rare,  though  the}'  furnish  a  great  amount  of 
discussion  in  our  fracture  literature. 

The  treatment  of  non-union  has  come  to  follow  a  certain  fairly 
regidar  routine :  (1)  Immobilization  persisted  in  for  at  least  six  months; 
(2)  irritation  of  the  ends  of  the  bone  fragments  by  friction  against  each 
other,  with  the  patient  anesthetized;  (3)  incision  down  upon,  and 
wiring  ^  of  the  fragments.  Each  operation  should  be  followed  b}'  a 
further,  long-continued  immobilization. 

Recentty  certain  investigations  in  metabolism,  in  immunity,  and  in 
the  processes  of  wound  healing  have  seemed  to  lead  to  a  hope  of  benefit 
from  novel  measures.  A  considerable  number  of  cases  of  non-union 
appear  to  have  been  cured  by  the  emploj-ment  of  Bier's  passive  h}-- 
peremia;  while  a  still  more  interesting  method  is  the  surrounding  of 
the  bone-ends  with  an  aseptic  blood-clot,  purposeh^  introduced  into 
the  tissues,  after  which  the  wound  is  allowed  to  heal  per  jprimam. 

At  this  stage  of  our  discussion  we  need  not  consider  special  forms 
of  treatment  for  fractures  in  general,  but  it  is  interesting  to  reflect  that 
from  time  to  time  in  the  past  strange  and  radical  changes  in  treatment 
have  been  undertaken,  have  been  abandoned,  and  have  been  revived. 
As  I  have  said  in  Chapter  XXVI,  the  beginner  would  do  well  to  read 
with  care  the  illuminating  essays  of  Sampson  Gamgee  on  the  treatment 
of  fractures,  published  more  than  twenty-five  years  ago.  That  dis- 
cursive but  delightful  writer  makes  clear  the  vital  importance  of  rest 
and  immobilization  for  damaged  bones  and  joints.  For  generations 
surgery  has  recognized  the  importance  of  this  principle;  but  surgery 
has  for  generations  also  endeavored  in  some  fashion  to  accelerate  union 
even  while  maintaining  rest  and  immobilization. 

Massage  of  recent  fractures  is  an  ancient  practice,  long  in  disuse 
among  modern  surgeons,  until  within  recent  years.  In  the  chapter  on 
Minor  Surgery  I  have  already  written  at  some  leng-th  on  this  topic. 
Surgeons  misapprehend  often  the  limits  and  possibilities  of  massage 

^  This  word  "  wiring"  is  used  as  a  general  term  to  indicate  some  form  of  fixing, 
whether  by  silver  wire,  by  nails,  by  screws,  or  by  one  of  the  numerous  forms  of 
plates  or  clamps  which  have  been  devised. 


854  MINOR    SURGERY — DISEASES    OF    STRUCTURE 

for  broken  bones.  There  is  the  too  frequent  custom  of  postponing 
masaii;e  until  after  the  splints  have  ])een  removed  permanently,  and  the 
patient  has  begun  voluntarily  to  move  the  limb.  Massage  at  this  time 
is  of  some  value,  but  its  greatest  value  is  found  in  following  the  so-called 
French  custom  of  employing  massage  daily  from  the  time  of  the  injury. 
I  employ  this  method  with  great  satisfaction.  Massage  stimulates  the 
circulation,  especially  in  the  lymphatic  vessels,  and  brings  fresh  blood 
to  the  part,  in  which  the  massage  induces  a  condition  of  active  hyper- 
emia. One  sees,  therefore,  that  in  a  sense  one  of  the  principles  of  the 
Bier  treatment  is  thus  attained — indeed,  Willy  Meyer  and  other  surgeons 
in  this  country  who  have  employed  faithfully  the  Bier  method,  find 
that  it  is  of  distinct  value  in  the  routine  treatment  of  fractures. 

In  the  case  of  simple  fractures  my  routine  method  is  to  remove  the 
bandages  on  the  third  day  or  as  soon  as  excessive  swelling  has  subsided ; 
and  then,  with  the  limb  firmly  supported  by  strapping  upon  splints, 
carefully  and  thoroughly  to  apply  the  massage.  If  convenient  and 
possible,  such  massage  is  renewed  daily,  or  every  second  day,  throughout 
the  patient's  convalescence. 

Not  only  is  union  accelerated  by  these  measures,  but  the  muscular 
tone  and  the  circulation  are  so  well  sustained  that  almost  as  soon  as 
the  splints  are  finally  removed  the  patient  finds  himself  able  in  fair 
measure  to  make  use  of  the  affected  limb. 

Let  us  now  take  up  a  consideration  of  simple  and  of  compound 
fractures. 

SIMPLE   FRACTURES 

While  we  understand  by  this  term  a  fracture  which  does  not  com- 
municate with  the  outer  air,  we  must  realize  that  there  are  varieties 
of  simple  fractures.  There  are  traumatic  fractures — fractures  due  to 
violence.  There  are  pathologic  fractures — fractures  due  to  the  breaking 
of  a  bone  weakened  by  disease  (osteomyelitis,  tuberculosis,  syphilis, 
sarcoma,  carcinoma,  rickets,  the  atrophy  of  old  age,  and  other  similar 
lesions) . 

Simple  fractures  may  consist  oi  fissures  only  in  the  bone;  of  sub- 
periosteal fractures,  in  which  case  the  periosteum  is  not  broken,  the 
fragments  are  not  displaced,  and  the  ordinary  signs  of  fracture  are  not 
apparent.  Frequently  this  condition  has  been  mistaken  for  a  sprain. 
There  are  green-stick  fractures,  in  which  case  one  side  only  of  a  long 
bone  is  splintered.  There  are  fractures  known  as  spiral  fractures, 
oblique  fractures,  V-fractures,  T-fi"i^Ptures,  Y-fractures — the  meanings 
of  all  of  which  terms  are  sufficiently  obvious,  and  they  are  employed  to 
indicate  merely  the  shapes  into  which  the  bones  are  splintered.  The 
following  table,  copied  from  Eisendrath's  excellent  article — a  table  for 
which  he  acknowledges  his  indebtedness  to  Scannell,  of  the  Boston  City 
Hospital — is  an  interesting  statement  of  the  frequency  of  various 
simple  fractures.^ 

1  Simple  fractures  entered  at  Boston  City  Hospital  between  1864  and  1905. 


SIMPLE   FRACTURES 


855 


Simple  Fractures.  Cases.  Per  cent. 

1.  Radius 4657  (13.45) 

2.  Humerus 3517  (10.16) 

3.  Ribs 3196  (  9.23) 

4.  Femur 2898  (  8.37) 

5.  Clavicle 2756  (  7.96) 

6.  Fibula 2344  (  6.77) 

7.  Metacarpus 1285  (  3.71) 

8.  Tibia 1259  (  3.63) 

9.  Skull 992  (  2.86) 

10.  Tarsus 947  (  2.73) 

11.  Phalanges  (upper  extremity) 798  (  2.30) 

12.  Inferior  maxilla 692  (  1.99) 

13.  Patella 660  (  1.90) 

14.  Ulna 630  (   1.82) 

15.  Facial  bones 538  (  1 .55) 

16.  Carpus 495  (  1.43) 

17.  Vertebra; 331  (  0.95) 

18.  Scapula 256  (  0.73) 

19.  Pelvis 208  (  0.60) 

20.  Metatarsus 168  (  0.48) 

21.  Phalanges  (lower  extremity) 78  (  0.22) 

22.  Superior  maxilla 70  (  0.20) 

23.  Sternum 40  (  0.11) 

24.  Coccyx 20  (  0.05) 

25.  Hyoid 1  (0.002) 

Both  bones  of  the  leg 3902  (11.20) 

Both  bones  of  the  arm 1875  (  5.10) 

The  symptoms  and  the  diagnosis  of  simple  fractures  fall  naturally 
into  a  common  paragraph.  We  hear  much  of  the  history  of  the  accident, 
its  general  effect  upon  the  patient,  and  of  the  age  of  the  patient.  These 
are  more  or  less  interesting  topics,  but  in  fact  they  have  but  the  most 
indirect  bearing  upon  the  diagnosis.  The  symptoms  even  of  the 
patient  are  of  far  less  consequence  than  are  the  objective  signs  which 
the  surgeon  observes.  For  example,  in  describing  a  fracture  a  writer 
will  tell  you  that  the  patient  fell  25  feet,  that  he  landed  upon  his  knee, 
that  he  experienced  great  shock,  that  he  is  seventy-five  years  of  age, 
that  he  was  unable  to  rise,  that  his  leg  is  paralyzed,  and  that  there  is  a 
bunch  on  the  outer  side  of  his  thigh.  This  is  all  very  well  and  might 
lead  the  reader  to  the  conclusion  that  the  patient  is  suffering  from  a 
fracture  of  the  shaft  of  the  femur;  whereas  he  may  have  a  fracture  at 
the  base  of  the  skull,  or  a  rupture  of  the  kidney,  which  will  account  for 
all  his  symptoms,  while  the  swelling  on  the  outer  side  of  the  thigh  is  a 
mere  hematoma.  No;  the  tmly  important,  characteristic,  and  final 
evidence  is  to  be  found  upon  an  examination  only  of  the  patient's  body 
by  the  surgeon  himself. 

There  are  certain  classic,  well-recognized,  and  positive  signs  of  frac- 
ture: deformity,  loss  of  voluntary  motion,  abnormal  mobility,  and 
crepitus  or  grating,  while  the  evidence  of  the  x-ray  confirms  the  diag- 
nosis. Such  is  the  positive  and  final  evidence  for  which  we  look.  The 
other  facts  in  the  history  are  more  or  less  interesting,  and  may  have 
their  bearing  upon  the  treatment  of  the  case,  but  they  are  not  of  first 
importance. 

I  ask  the  reader  to  refer  again  to  Chapter  XXVI  for  a  descrip- 
tion of   a  proper   method  of   handling  and  examining  cases  of   sus- 


856  MINOR   SURGERY — DISEASES   OF   .STUICTLUE 

pccted  fracture.  Moreover,  as  Scuclder  states  in  the  first  edition  of 
his  admirable  book  on  the  Treatment  of  Fractures,  "The  general 
emi^loyment  of  anesthesia  in  the  examination  of  the  initial  treatment 
of  fractures,  especially  of  those  near  or  involving  joints,  has  made 
diag-nosis  more  accurate  and  treatment  more  intelligent.  .  .  .  This 
great  certainty  in  diagnosis  has  suggested  more  direct  and  simpler 
methods  of  treatment.  .  .  .  The  attention  of  the  student  is  diverted 
from  theories  and  apparatus  to  the  actual  conditions  that  exist  in  the 
fractured  bone,  and  he  is  encouraged  to  determine  for  himself  how  to 
meet  the  conditions  found  in  each  individual  case  of  fracture." 

The  patient's  interest  in  his  own  case  is  a  factor  in  the  situation 
which  will  often  puzzle  the  beginner  or  the  inexperienced  practitioner. 
The  patient  wishes  to  know  how^  perfect  will  be  his  use  of  the  damaged 
limb,  and  how  long  he  is  to  be  laid  up.  His  interest  in  the  case  goes 
no  further  than  this,  unless,  as  frequently  happens,  he  is  contemplating 
a  suit  for  damages.  It  is  the  meeting  of  these  questions  so  difficult  of 
accurate  answer,  and  the  annoyance,  with  the  possible  reflection  on 
his  own  skill,  associated  with  a  pending  legal  suit — it  is  these  considera- 
tions which  have  rendered  the  subject  of  fractures  a  grievance  and  an 
offense  to  many  a  surgeon. 

The  clinical  course  of  an  average  simple  fracture  of  one  of  the 
long  bones  presents  certain  characteristics.  The  limb  in  the  neighbor- 
hood of  the  fracture  is  swollen  and  tense  from  extravasated  blood  and 
lymph.  The  parts  become  pigmented,  the  limb  aches  and  is  extremely 
painful  on  being  moved,  or  from  involuntary  muscular  twitching,  if 
the  parts  are  not  kept  at  rest  by  splints  and  bandages.  During  the 
first  week  there  is  commonly  a  slight  rise  of  temperature  (the  so-called 
aseptic  fever).  If  the  limb  is  severely  crushed,  particles  of  fat  may 
escape  into  the  circulation,  may  cause  fat  embolism  in  various  organs, 
and  may  be  excreted  in  the  urine. 

If  all  goes  well,  however,  and  the  injury  be  promptly  treated,  the 
swelling  subsides  gradually,  and  the  pain  diminishes  and  disappears, 
so  that,  in  the  course  of  a  week,  the  patient  rests  comfortably,  and  is 
conscious  only  of  a  disabled  and  useless  limb.  In  the  course  of  a 
few  days  the  reparative  changes  about  the  seat  of  the  fracture  become 
apparent.  Gradually,  a  soft  tumor  or  collection  of  exudate  of  var3'Ing 
size  develops.  This  is  known  clinically  as  the  "  callus."  At  first  soft,  it 
gradually  becomes  harder,  and  in  the  course  of  weeks  smaller.  It 
constitutes  nature's  plastic  mold  or  splint,  which  binds  together  the 
damaged  fragments.  For  some  wrecks  also  one  can  ascertain  the 
progress  of  the  convalescence  by  examining  this  callus.  While  it  is 
soft,  the  bone  fragments  move  easily  within  it.  As  it  becomes  hard 
and  ossified  the  union  of  the  bones  becomes  firmer,  so  that,  in  the  course 
of  time,  a  solid  union  wdthin  the  callus  is  assured.  The  repair  of  carti- 
lage as  well  as  of  bone  follows  this  course. 

The  time  required  for  the  repair  of  a  simple  fracture  is  usually  about 
sixty  days.  I  find  it  stated  in  the  Cieneral  Surgery  of  Lexer  and 
Bevan  that  two  weeks  are  rec^uired  for  the  repair  of  fractures  of  the 


SIMPLE    FRACTURES  857 

phalanges,  three  weeks  for  those  of  the  metatarsal  bones  and  the  ribs, 
four  weeks  for  those  of  the  clavicle,  five  weeks  for  those  of  the  bones 
of  the  forearm,  six  weeks  for  those  of  the  humerus  and  fibula,  seven 
weeks  for  those  of  the  neck  of  the  humeiiis  and  the  tibia,  eight  weeks 
for  those  of  both  bones  of  the  leg,  ten  weeks  for  those  of  the  shaft  of 
the  femur,  and  twelve  weeks  for  those  of  the  neck  of  the  femur;  while 
consolidation  occurs  much  more  rapidly  in  children  and  is  complete 
in  most  of  their  bones  in  from  two  to  three  weeks. 

The  treatment  of  simple  fractures  follows  naturalh'  enough  upon 
the  diagnosis.  A  great  mass  of  nebulous  talk  and  writing  has  been 
indulged  in  regarding  the  treatment  of  fractures.  There  are,  in  fact, 
two  vital  principles  involved.  If  these  principles  are  observed,  all  should 
go  well. 

The  fragments  of  bone  must  be  brought  into  reasonable  apposition 
and  held  there. 

The  patient  must  be  made  comfortable. 

Simple  as  are  these  two  principles,  one  is  astonished  constant^  at 
finding  them  neglected.  Ordinarily,  it  is  not  difficult  to  bring  frag- 
ments into  apposition.  As  a  general  thing,  the  patient  must  be  anesthe- 
tized,— with  gas,  ether,  or  chloroform, — when  promptly  the  tense  muscles 
relax  and  the  fragments  can  easily  be  brought  together.  If  there  is 
still  difficulty  in  making  the  approximation,  the  surgeon  may  do  tenot- 
omy— especially  of  the  tendon  of  Achilles — or,  if  comminuted  fragments 
interfere  with  each  other  or  protrude  into  a  joint,  he  may  cut  down 
upon  and  straighten  out  the  tangle.  We  use  the  term  reduction  to 
indicate  the  process  of  bringing  the  fragments  into  apposition.  The 
popular  word  "set"  has  little  meaning.  It  is  far  more  difficult  to  fix 
and  immobilize  the  reduced  fragments  than  it  is  to  reduce  them,  for 
with  returning  consciousness,  after  anesthesia,  the  patient  involun- 
tarily contracts  his  muscles,  and  muscular  contraction  tends  to  throw 
the  fragments  out  of  place.  The  surgeon  must,  therefore,  apply  splints 
which  shall  hold  the  fragments  and  shall  counteract  muscular  contrac- 
tion. Splints  must  be  long  enough  to  hold  fixed  the  adjacent  joints, 
and  must  be  so  molded  and  padded  as  to  lie  comfortably  and  snugly 
upon  the  limb. 

We  employ  two  distinct  t}-pes  of  splints — those  which  but  partially 
encircle  the  limb,  leaving  open  spaces  through  which  the  seat  of  fracture 
may  be  readily  inspected  from  time  to  time;  and  encircling  splints 
molded  entirely  about  the  limb.  Strips  of  wood  properly  padded 
are  types  of  the  first  class  of  splints;  plaster  bandages  are  types  of  the 
second  class,  and  each  class  of  splints  has  its  appropriate  place.  In 
general  terms,  we  use  the  removable  wooden  splints  upon  fractures 
which  have  been  reduced  with  difficulty,  which  tend  readily  to  slip 
out  of  line,  and  are  surrounded  by  swelling  and  distention  of  the  soft 
parts;  while,  conversely,  we  employ  the  con&iing  and  encircling  plasters 
(the  popular  term  "plaster  cast"  is  erroneous)  to  hold  in  position  some 
fractures  readily  reduced  and  associated  with  little  or  no  swelling.  At 
the  same  time,  if  the  surgeon  is  not  employing  frequent  massage,  he 


858  MINOR   SLTRGERY — DISEASES   OF   STRUCTURE 

ma}^  well  dress  the  first  class  of  fructures  in  plaster  after  soft  union 
has  begun  and  the  primary  swelling  has  subsided.' 

There  are  sundry  special  apparatus  for  special  fractures,  such  as 
the  familiar  Buck's  extension  for  fracture  of  the  femur.  I  shall  men- 
tion these  apparatus  when  I  come  to  discuss  the  treatment  of  special 
fractures. 

COMPOUND  FRACTURES 

Compound  fractures  call  for  special  and  important  initial  treatment 
in  order  to  render  them  sim{)le.  When  once  simple,  we  treat  them 
upon  the  rules  already  laid  down.  A  compound  fracture  presents  an 
extremely  ugly  form  of  lacerated  wound,  with  tearing  up  of  the  soft  parts, 
extravasation  of  blood,  sometimes  protrusion  of  a  broken  bone,  and 
commonly  a  small  punctured  opening  through  the  skin.  We  treat  the 
wound  of  the  soft  parts,  and  then  the  fracture. 

The  surgeon  should  invariably  see  that  the  patient  is  anesthetized 
for  the  first  dressing.  He  must  then  shave  and  disinfect  a  large  area 
of  skin  about  the  wound,  employing  the  ordinary  method  of  skin  dis- 
infection; he  must  wash  out  the  wound,  using  hydrogen  dioxid  and 
sterile  salt  solution;  he  must  remove  loose  fragments  of  bone,  and  he 
must  provide  adequate  drainage.  Frequently  it  may  seem  well  to 
him,  while  the  wound  is  open,  to  fix  the  fragment  by  wiring.  Having 
thoroughly  cleansed  and  dressed  the  seat  of  fracture,  he  must  then 
put  up  the  limb  in  fixation  splints.  For  this  purpose  splint-wood 
strips  are  commonly  most  convenient,  for  they  may  readily  be  removed 
when  the  superficial  wound  is  to  be  dressed.  In  some  cases  of  a  simple 
character  it  may  seem  best  to  fix  the  limb  in  plaster  bandages,  and  to 
cut  out  a  window  from  the  plaster  which  shall  give  access  to  the  wound 
for  its  subsequent  dressings. 

Compound  fractures  are  less  common  than  simple  fractures;  and 
various  statistics  show  the  proportion  of  compound  to  simple  to  be 
about  as  one  in  four;  though  certain  bones,  such  as  the  phalanges,  are 
more  subject  to  compound  fracture  than  to  simple  fracture. 

The  following  table,  taken  from  Eisendrath's  article,  gives  one  an 
excellent  idea  of  the  relative  frequency  of  the  various  compound  frac- 
tures. The  student  should  read  this  table  in  connection  with  the  table 
on  simple  fractures  which  I  gave  on  p.  S55. 

Compound  Fractures? 

Cases.  Per  cent. 

1.  Skull 525  (14.45) 

2.  Phalanges  (upper  extremity) 488  (13.43) 

3.  Metacarpus 272  (  7.48) 

4.  Tibia 238  (  6.50) 

5.  Humerus 219  (  6.02) 

6.  Tarsus 203  (  5.58) 

7.  Carpus 152  (  4.80) 

8.  Femur 146  (  4.01) 

9.  Facial  bones 119  (  3.27) 

1  Plaster  bandages  may  be  fashioned  so  as  to  be  removed  and  reapplied  readily 
by  splitting  them  down  after  they  have  dried  upon  the  Umb. 

2  Compound  fractures  entered  at  Boston  City  Hospital  between  1864  and   1905. 


SPECIAL   FRACTURES   AND   THEIR  TREATMENT  8o9 

Cases.  Per  cent. 

10.  Phalanges  (lower  extremity) 69  (  1 .88) 

11.  Inferior  maxilla ^G  (  1 .80) 

12.  Radius 6-1  J-;0 

Ulna 04  (  1.70) 

13.  Fibula «2  (  1.70) 

14.  Metatarsus 2.  (  0.74 

15.  Superior  maxilla 1^  <  ^-27) 

Claviele 10  (  0-27 

le.Ribs 8  0-22 

17.  Patella 7  0.19 

IS.  Pelvis 6  0.16 

19.  Seapula 3  0.08 

20.  Vertebra 0.02 

Sternum 1  (  0.02) 

Both  bones  of  the  leg 610  (l^-70) 

Both  bones  of  the  arm 262  (  7.02) 

"VYe  may  not  leave  the  general  subject  of  fractures  and  their  treat- 
ment without  referring  to  the  possibility  of  the  surgeon  himself  causing 
further  damage  to  the  injured  limb  through  his  own  ill-regulated  treat- 
ment. I  have  already  spoken  of  malunion  and  the  disastrous  results 
of  failure  properly  to  disinfect  a  compound  fracture.  Another  not 
infrequent  and  doleful  result  of  treatment  is  the  so-called  Volkmann's 
contracture.  By  this  term  we  understand  a  contraction  or  flexion  of 
the  fingers  and  the  wrist  following  the  treatment  of  fractures  about  the 
elbow-joint  and  in  the  forearm.  Volkmann's  contracture  appears  often 
within  three  or  four  days  after  the  patient's  accident.  It  is  associated 
with  loss  of  power  in  the  muscles  of  the  forearm,  most  commonly 
in  young  children.  It  is  an  extremely  serious  matter,  though  if  we 
recog-nize  it  early,  we  can  check  its  progress.  The  cause  of  the  con- 
tracture is  probably  an  ischemic  necrosis  of  the  muscles,  dependent 
upon  too  great  a  pressure  by  splints  against  the  soft  parts.  ^  Such 
pressure  interferes  with  the  blood-supply,  so  that  the  muscle  dies  and 
is  replaced  by  scar  tissue.  I  have  already  discussed  this  condition  and 
its  treatment  in  Chapter  XXVII. 

Let  us  now  consider  briefly  the  more  important— 

SPECIAL  FRACTURES  1  AND  THEIR  TREATMENT 

Fractures  of  the  skull  and  of  the  vertebrce  are  discussed  in  Chapters 
XXIV  and  XXV  of  this  book. 

Ribs 

The  ribs  and  costal  cartilages  are  broken  most  commonly  by  blows 
and  crushing  forces.  There  results  instant  and  characteristic  distress: 
shortness  of'breath,  stabbing,  localized  pain  with  each  respiration,  and 
sometimes  the  spitting  of  blood  if  the  lung  be  damaged.  The  surgeon 
can  bring  out  a  point  of  pain  by  manual  compression  of  the  thorax, 
which  tends  to  ''start"  the  involved  rib  at  the  point  of  fracture.     He 

1 1  am  indebted  to  C.  L.  Scudder  for  permission  to  draw  largely  upon  his 
iUustrations  in  The  Treatment  of  Fractures,  sixth  edition,  1907.  _  The  reader  is 
referred  also  to  L.  A.  Stimson,  Fractures  and  Dislocations,  fifth  edition,  1907. 


860 


MINOR   SURGERY — DISEASES    OF    STRUCTURE 


may  feel  crepitus  on  palpating  the  seat  of  injury,— although  crepitus 
is  by  no  means  a  constant  sign  in  fractured  ribs;  but  perhaps,  most 
important  of  all,  he  can  hear  creaking  with  every  respiration  of  the 
patient,  by  placing  his  stethoscope  upon  the  suspected  area. 

There  may  be  distressing  complications  in  connection  with  a  rib 
fracture — compound  openings  and  lacerations  of  tlio  pleura  and  lung. 
I  have  already  discussed  this  matter  in  Chaplci'  .\1X. 


Fif^.  .'i.'^'.t.     Fraoturod  ribs  (Warren  Museum"). 

Compound  fracture  of  ribs,  however,  is  not  common,  and  far  the 
most  frequent  cases  are  the  simple  single  fractures  whose  victims 
present  themselves  at  the  dispensary  or  the  surgeon's  office.  These 
people  are  in  constant  distress,  and  I  know  of  few  bone  injuries  which 
are  capable  so  promptly  of  being  relieved. 


SPECIAL    FRACTURES    AND   THEIR   TREATMENT 


861 


The  treatment  of  fractured  rib  consists  in  immobilizing  the 
thoracic  ciige  so  as  to  limit  costal  respiration  and  force  the  patient  to 
respiration  by  the  diaphragm.  There  are  numerous  methods  of  im- 
mobihzing  the  chest,  but  by  far  the  most  effective  is  wrapping  it  in  a 
firm  swathe  of  surgeon's  plaster;  or,  if  a  swathe  be  not  at  hand,  in 
successive  layers  of  plaster  strips  encircling  the  chest  and  laid  on  in 
the  manner  of  clapboards. 


Fig.  540. — Fracture  of  the  ribs.  Starting  the  application  of  the  adhesive-plaster 
swathe  to  encircle  the  trunk.  Fixation  of  initial  end  of  the  swathe  at  the  spine. 
Notice  that  the  swathe  is  held  taut  as  it  is  applied  (Scudder). 

After  this  dressing,  the  patient  is  usually  so  comfortable  that  he  walks 
about  without  distress,  and  often  can  return  at  once  to  his  occupation. 


Sternum 

The  sternum  is  fractured,  the  most  frequent  fracture  being  at  the 
point  of  union  of  the  manubrium  and  the  body  of  the  bone.  I  have 
seen  one  such  fracture  in  the  case  of  a  football  player  whose  manu- 
brium was  crushed  in  by  a  blow.  The  symptoms  are  quite  similar  to 
those  of  fractured  rib,  and  the  deformity  is  so  characteristic  that  the 
diagnosis  is  extremely  easy.  The  patient  stands  in  a  hollow-chested 
attitude,  while  the  examiner's  finger  sinks  at  once  into  the  pit  formed 
by  the  depressed  fragment. 

The  fracture  is  often  reduced  spontaneously  through  the  patient's 
coughing  or  sneezing.  Sometimes  the  surgeon  may  reduce  the  frac- 
ture by  turning  the  patient  on  his  back  and  making  traction  upon  the 


862  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

arms,  while  an  assistant  steadies  the  chest.     If  this  nianevivcr  fails,  one 
may  easily  cut  clown  upon  the  fragment  and  elevate  it.     After  the 


Fig.  541. — Position  in,  and  method  of  reduction  of,  fracture  of  the  sternum.     Notice 
positions  of  hands  of  surgeon  and  assistant  (Scudder). 

bones  are  replaced,  the  patient  should  be  enveloped  in  a  plaster  swathe 
and  kept  quietly  in  bed  for  three  weeks  at  least. 

Pelvis 

Fracture  of  the  pelvis  is  frequently  seen  in  large  hospital  practice, 
and,  as  Scudder  points  out,  pelvic  fractures  fall  into  two  groups — 
fractures  of  the  individual  bones  without  injury  to  viscera,  and  frac- 
tures at  different  points  in  the  pelvic  ring  associated  with  damage  to  the 
viscera. 

One  can  palpate  with  fair  thoroughness  the  whole  pelvic  ring,  in 
spite  of  the  apparent  inaccessibility  of  the  bones  involved.  For  with  a 
little  care  and  patience  fingers  in  the  rectum  or  vagina  may  search  out 
all  parts  of  the  pelvis.  Moreover,  the  external  examination  alone 
reveals  fractures  often.  The  surgeon  grasps  the  iliac  crests  and  by 
pressure  and  rotation  detects  the  fracture. 

The  treatment  of  these  pelvic  injuries  has  been  too  much  slighted 
and  made  a  matter  of  routine.  Commonly,  we  see  the  patient  wrapped 
snugly  in  a  plaster  swathe  and  left  to  roll  about  in  bed  without  further 
support.  The  plaster  swathe  is  a  valuable  remed}',  but  its  value  is 
greatly  increased  if  the  patient  be  bound  upon  a  well-fitting  Bradford 
frame,  for  thus  immobility  is  made  more'  certain,  and  the  care  of  the 
patient's  bowels  and  back  is  made  much  more  easy.  In  case  the 
acetabulum  and  pubis  are  fractured,  it  is  often  well  to  immobilize  the 
patient's  legs  by  the  application  of  long  confining  outside  splints,  which 
shall  extend  from  the  axillee  to  six  inches  below  the  heels. 

It  frequently  happens  that  the  urethra,  the  bladder,  and  other 
pelvic  structures  are  torn  when  the  pelvic  bones  are  displaced.  Extrav- 
asation of  urine  leading  to  peritonitis  even  may  result.  I  have  al- 
ready, in  Chapters  XIV  and  XV,  discussed  these  complicated  conditions. 


special  fractures  and  their  treatment  863 

Clavicle 

The  clavicle  is  not  broken  as  frequently  as  is  generally  supposed, 
though  its  fracture  is  common  enough.  It  stands  fifth  in  the  Boston  City 
Hospital  list,  and  seventh  in  other  lists  which  I  have  consulted.  When 
one  remembers  that  the  clavicle  is  subcutaneous  throughout  its  extent, 
that  it  is  a  weight-bearing  bone  of  great  importance;  and  that  every 
motion  of  the  arm  is  transmitted  to  it,  one  sees  how  inevitably  it  is 
subjected  to  fracture  by  both  direct  and  indirect  violence.  A  collar- 
bone broken  b}^  the  victim's  falling  from  a  horse,  by  being  stmck  upon 
the  shoulder,  or  by  being  jammed  between  wagons,  is  broken  by  in- 


Fig.  542. — Fracture  of  right  clavicle  (Massachusetts  General  Hospital). 

direct  violence,  and  such  is  the  nature  of  the  injury  which  usually 
causes  fracture  of  the  clavicle.  A  direct  violence  fracture  of  the  clavicle 
is  not  common.  One  sees  also  that  indirect  violence  may  cause  green- 
stick  fracture  of  the  clavicle  in  young  children — the  common  form  of 
collar-bone  fracture  in  childhood. 

A  clavicle  commonly  breaks  in  its  middle  third,  though  direct 
violence,  as  by  a  bullet,  may  shatter  it  at  any  point  in  its  course.  With 
the  clavicle  broken,  the  shoulder  falls  foi-^^ard  and  drops  inward  so  that 
the  outer  fragment  of  the  bone  is  carried  below  the  inner  fragment  and 
overlaps  it  in  front,  while  the  inner  fragment,  to  which  the  sternomastoid 
muscle  is  attached,  is  tilted  slightly  upward.  The  patient  stands  with 
his  head  inclined  to  the  injured  side,  so  as  to  relax  the  pull  of  his  stemo- 


864 


MINOR   SURGERY — DISEASES   OF   STRUCTURE 


mastoid  muscle.  He  relieves  his  pain  further  by  sui)p(jrlins  his  in- 
jured arm  in  the  opposite  hand. 

If  a  child  is  the  victim  of  a  green-stick  fracture  of  the  clavicle,  the 
characteristic  attitude  is  nuich  less  marked.  The  shoulder  droops 
less,  while  a  tender  swelling  appears  at  the  seat  of  the  fracture.  In  the 
case  of  a  very  obscure  fracture,  a  characteristic  point  of  pain  can  be 
brought  out  by  the  surgeon's  placing  a  hand  on  the  outer  side  of  either 
shoulder  and  crowding  the  shoulders  together. 

The  treatment  of  a  completely  fractured  clavicle  is  not  always 
satisfactory.  The  displacement  can  be  corrected  and  the  proper  posi- 
tion can  be  mahitained,  but  this  is  not  always  accomplished.     Obvi- 


Fig.  54.3. — Fracture  of  the  left  clav- 
icle. Modified  Sayre  dressing.  Towel 
circular  of  upper  arm  held  by  adhesive 
plaster.  Adhesive-plaster  strap  ready 
(Scudder). 


Fig.  544. — Fracture  of  the  left  clav- 
icle. First  adhesive-plaster  strap  ap- 
plied. Shoulder  carried  backward. 
Fixed  point  established  above  middle 
of  humerus  (Scudder). 


ously,  the  indications  for  treatment  are  to  carry  the  shoulder  with  the 
outer  fragment  of  the  clavicle  upward,  outward,  and  backward.  As 
the  old  writers  have  pointed  out,  the  proper  position  can  best  be  secured 
b}'  laying  the  patient  flat  on  his  back  on  a  hard  mattress  with  a  small 
pillow  between  his  shoulders.  Few  patients,  however,  are  willing  to 
submit  to  treatment  in  bed  for  this  rather  trifling  injury. 

The  modified  Sayre  dressing  is  usually  satisfactory,  however;  it 
holds  the  fragments  in  fair  position  and  allows  the  patient  to  walk 
about.  This  dressing  is  made  of  adhesive  plaster:  "Provide  three 
strips  of  plaster,  4  inches  wide,  and  long  enough  to  extend  once  and  a 
half  around  the  body.     The  skin  surfaces  that  are  to  come  in  contact — 


SPECIAL    FUACTUUES    AND    THEIR   TREATMENT 


865 


Fig.  545. — Fracture  of  the  left  clav- 
icle. First  adhesive-plaster  strap  applied. 
Second  adhesive-plaster  strap  being  ap- 
plied. Hole  in  plaster  for  olecranon  visi- 
ble. Note  pad  for  wrist  and  folded  towel 
protecting  skin  of  arm  and  chest  (Scud- 
der) 


Fig.  546. — Fracture  of  the  left  clav- 
icle. First  and  second  adhesive- 
plaster  straps  applied.  Pad  in  left 
hand.  Shoulder  pulled  backward  and 
elevated  (^Scudder). 


Fig.  547. — Fracture  of  the  right  clav- 
icle. Modified  Sayre  dressing.  Pos- 
terior view.  Shoulder  elevated  and 
pulled  backward.  Folded  towel  seen  in 
axilla  for  protection  to  skin  (Scudder). 


55 


Fig.  54S. — Fracture  of  the  clavicle. 
Method  of  application  of  a  Velpeau 
bandage.  Note  the  order  and  direc- 
tion of  the  turns  1,  2,  3,  4,  and  5.  Note 
position  of  the  forearm  and  arm  of  the 
uninjured  side  (Scudder). 


866  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

namely,  the  axilla,  and  chest,  and  forearm — are  separated  by  compress 
cloth  and  powder.  A  dressing  towel  folded  is  snugly  pinned  high  up 
about  the  upper  arm.  One  end  of  the  first  adhesive  strap  is  fastened 
loosely  about  the  towel-protected  arm  with  a  safety-pin.  While  an 
assistant  holds  the  shoulder  well  back,  the  arm  is  carried  backward  and 
held  by  fastening  the  first  adhesive  strap  about  the  body.  The  second 
strap,  with  a  hole  in  it  to  receive  the  point  of  the  elbow,  is  started  upon 
the  posterior  surface  of  the  injured  shoulder  and  carried  under  the 
elbow  of  the  injured  side  and  over  the  sound  shoulder.  The  forearm  is 
thus  flexed  and  rests  upon  the  chest.     In  applying  this  second  strap  the 


^  -"%F 

J' 

\\  1 

Fig.  549. — Fracture  of  the  clavicle  and  subluxation  of  the  acromioclavicular 
joint.  Xotice  elevation  of  shoulder  by  pressure  on  the  flexed  elbow  and  counter- 
pressure  on  the  clavicle  by  a  bandage  and  a  pad  ( X )  placed  internal  to  the  acromiocla- 
vicular joint  (Scudder). 

patient's  shoulder  is  raised,  and  his  elbow  is  carried  fonvard,  thus 
forcing  the  shoulder  slighth'  upward  and  backward  to  the  fixed  point 
used  as  a  fulcrum.  A  third  strap  may  be  placed  aroimd  the  tinank  and 
arm  to  steady  all  in  good  place."'  The  surgeon  may  apply  a  Velpeau 
bandage  over  this  dressing  to  give  the  patient  increased  comfort. 

The  results  of  treatment  are  usualh'  satisfactory  so  far  as  function 
is  concerned,  though  it  commonh'  happens  that  some  slight  deformity 
remains  for  a  long  time.  This  must  be  inevitable  in  the  case  of  any 
broken  bone  the  fragments  of  which  cannot  be  seized  directly,  manipu- 

1  C.  L.  Scudder,  ibid. 


SPECIAL    FRACTURES    AND    THEIR   TREATMENT 


867 


lated,  and  splintctl.  For  this  reason  it  may  seem  well  in  the  case  of 
badly  overriding  and  irreducible  fragments  of  the  clavicle  to  cut  down 
upon  and  wire  the  bones. 

Scapula 

The  scapula  is  one  of  the  most  complicated  bones  in  the  body,  so 
that  its  fractures  are  manifold.  We  have  to  consider  the  great  wing- 
like body  of  the  scapula,  the  glenoid  cavity,  the  coracoid  process,  the 
spine,  and  the  acromion  process. 

This  bone  is  usually  fractured  by  direct  violence — by  a  crushing 
blow.  There  are  no  characteristic  signs  or  symptoms  of  fractured 
scapula.     The  patient  knows  merely  that  he  suffers  great  pain  in  the 


Fig.  550. — Fractured  scapula. 

neighborhood  of  the  shoulder  and  that  he  must  support  the  correspond- 
ing arm  in  order  to  obtain  any  relief.  The  surgeon  discovers  grating, 
swelling,  and  tenderness,  while  the  x-ray  must  be  relied  upon  for  the 
accurate  diagnosis. 

If  the  acromion  process  alone  be  broken,  the  line  of  fracture  ordin- 
arily is  outside  the  acromioclavicular  joint.  If  the  fracture  happens 
to  lie  on  the  inner  side  of  this  joint,  there  results  a  considerable  flatten- 
ing of  the  shoulder.  This  injury  may  be  mistaken  for  a  dislocation 
of  the  humerus,  but  one  eliminates  this  dislocation  by  finding  the  head 
of  the  humerus  in  the  glenoid  cavity. 

The  rare  fracture  of  the  neck  of  the  scapula,  however,  may  well  be 
mistaken  for  a  dislocation  of  the  shoulder. 


868  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

All  treatment  of  fructuies  of  the  scapula  is  directed  to  raising  and 
immobilizing  the  shoulder.  The  bone  fragments  cannot  be  approxi- 
mated accurately  except  by  open  treatment,  which  is  not  usually 
advisable.  We  realize  that  the  shoulder  muscles,  especially  the  deltoid 
and  the  rotators,  bind  together  in  a  natural  swathe  all  parts  of  the 
scapula.  The  surgeon  may,  therefore,  feel  reasonably  confident,  in 
the  case  of  uncomplicated  scapula  fractures,  that  he  can  secure  a  satis- 
factory result  by  enveloping  the  shoulder  in  a  large  thick  pad  of  wadding, 
bringing  the  corresponding  hand  toward  the  opposite  shoulder,  and 
binding  all  the  parts  firmly  together  in  a  comfortable  ^'elpeau  bandage. 

The  fragments  unite  quickly — usually  in  from  three  to  four  weeks. 
After  removing  the  final  dressings,  the  surgeon  should  see  to  it  that 
the  patient  be  given  frequent  massage  and  active  and  passive  move- 
ments, daily  if  possible,  and  for  a  month  at  least,  if  he  is  to  escape 
permanent  crippling  from  a  stiff  and  painful  shoulder. 

Humerus 

The  humerus  is  one  of  the  im])ortant  bones  entering  into  the  shoulder- 
joint,  so  that  fractures  of  this  bone  may  affect  vitally  the  value  and 
function  of  that  joint.  Practitioners  sometimes  speak  as  though  the 
humerus  were  the  only  important  bone  concerned  with  the  shoulder- 


Head  and  articular 
surface 


Surgical  neck 


Fig.  551. — Upper  end  of  humerus.     Inner  view  (Scudder). 

joint,  but  our  brief  discussion  of  fractures  of  the  scapula  must  have 
shoA\Ti  that  both  scapula  and  humerus  are  of  nearly  equal  value  to  the 
proper  movements  of  the  shoulder-joint. 

The  accompanying  three  cuts  will  remind  the  reader  of  the  bony 
outlines  of  these  parts.  Fig.  551  especially  shows  how  the  point  of 
the  shoulder  is  formed  bv  the  head  of  the  humerus  and  not  bv  the  aero- 


SPECIAL   FRACTURES   AND    THEIR  TREATMENT 


869 


mion.  while  the  close  relation  of  the  coracoid  process  with  the  humerus 
is  a  fact  e;enorallv  overlooked. 


Anatomic  neck 


Surgical  neck 


Great  tuberosity 


L  Jl 

Fig.  552. — Upper  end  of  huiiicnis.     Anterior  view  (Scudder). 


Clavicle 


Bicipital  groove, 


Great  tuberosity -~ 
of  humerus 


Acromioclavic- .    *% 

ular  joint  ^ 


Spine  of  scapula' 


Coracoid  process 


Fig.  553. — View  of  bones  of  the  shoulder  from  above.  Notice  acromioclavicular 
joint,  its  relations  to  bicipital  groove  and  coracoid  process.  The  point  of  the  shoulder 
is  made  by  the  great  tuberosity  of  the  humerus  (Scudder). 

There  are  three  important  types  of  injury  to  the  humerus  in  the 
neighborhood  of  the  shoulder-joint — a  fracture  through  the  anatomic 
neck;    a  fracture  through  the  surgical  neck;    and  a  fracture  at  either 


870 


MINOR    SURGEHY^DISEASES   OF    .STRUCTURE 


one  of  these  points,  associated  with  dislocation  of  the  head  of  the  bone 
out  of  the  glenoid  cavity. 

If  a  fracture  of  the  humerus  in  the  region  of  the  shoulder  be  suspected, 
the  patient  should  be  anesthetized  for  proper  and  complete  examina- 
tion. Without  anesthesia,  even  though  the  x-ray  be  used,  it  is  not 
always  possible  accurately  to  determine  the  extent  of  the  injury;  while 
anesthesia  is  of  great  assistance  to  the  surgeon  in  the  reduction  and 
fixation  of  the  fiagTr.ents.  especially  and  obviously  if  he  is  compelled  to 
treat  them  by  the  open  method.     It  is  of  first  importance  to  be  certain 

/ 


Fig.  5.54. — Bimanual  paljjation  of  axilla. 

that  the  head  of  the  bone  is  in  the  glenoid  cavity.  One  can  almost 
always  ascertain  this  fact  by  the  method  of  bimanual  palpation — the 
fingers  of  one  hand  being  pushed  high  up  into  the  axilla  beneath  the 
pectoralis  major  muscle,  while  the  fingers  of  the  other  hand  press 
down  upon  the  opposing  fingers  through  the  pectoralis  major.  If 
the  head  of  the  humerus  is  in  its  socket  the  surgeon  will  find  nothing 
but  the  pectoralis  muscle  inter\'ening  between  his  two  hands,  which 
may  then  be  closely  approximated.  On  the  other  hand,  if  the  head 
of  the  bone  be  outside  of  its  socket,  it  will  lie  somewhere  within  the 
axillary  folds,  and  will  present  an  abnormal  and  clearly  felt  obstacle 


SPECIAL   FRACTURES    AND   THEIR   TREATMENT 


871 


between  the  examining  fingers.  I  have  never  known  this  bimanual 
test  to  fail,  though  I  have  never  seen  it  mentioned  in  text-books.  The 
other  ordinary  methods  of  examining  the  shoulder  are  well  illustrated 
in  the  figures  of  the  text. 

The  surgeon's  first  interest  then  in  making  an  examination  of  the 
shoulder  is  to  determine  whether  the  injury  is  a  mere  dislocation  of 
the  head  of  the  bone  or  is  a  fracture  of  the  humerus.  The  presenting 
deformities  of  each  injury  often  appear  quite  similar.  In  the  case  of  a 
simple  didocalion,  however,  one  sees  the  familiar  flattening  of  the 
deltoid;  while  the  elbow  is  carried  out  from  the  side,  the  forearm 
apparently  is  lengthened,  the  hollow  in  front  of  the  shoulder  is  obliter- 
ated, and  the  subpectoral  groove  is  lowered,  as  tho  ficui-o  illustrates. 
In  the  case  of  many  fractures,  on  the  other 
hand,  the  pectoral  line  is  accentuated  rather 
than  flattened,  the  arm  hangs  limp  and  flail- 
like, while  the  apparent  length  of  the  upper 
arm  is  diminished  as  compared  with  its 
fellow\ 

In  all  cases  of  shoulder  injury  examine 
first  the  sound  side  and  then  the  afTected 
side. 

Fracture  of  the  anatomic  neck  of  the 
humerus  is  quite  common  in  elderly  per- 
sons. It  can  be  made  out  readily  with  a 
patient  under  anesthesia,  but.  not  often 
without  anesthesia.  Crepitus  may  or  may 
not  be  felt.  The  fragments  may  or  may 
not  be  impacted ;  and  the  fracture  is  wholly 
intracapsular.  This  injury  often  goes  un- 
recognized; it  is  mistaken  for  a  ''sprain," 
so  that  there  results  a  permanently  stiff- 
ened and  painful  shoulder. 

If  the  fracture  be  obviously  impacted, 
the  fragments  must  not  be  broken  up,  but 
the  arm  must  be  slung  and  held  immobilized 
until  the  swehing  of  the  soft  parts  has  sub- 
sided. After  that — say,  in  ten  days  or  two 
weeks  from-  the  accident — the  joint  should 
be  treated  actively— by  passive  movements,  by  heat,  by  Bier's  hy- 
peremia, and  by  massage,  while  the  patient  should  be  encouraged  to  use 
the  arm  as  much  as  possible  within  the  limits  of  serious  discomfort. 

Separation  of  the  upper  epiphysis  in  children  is  a  lesion  quite 
similar  to  a  loose  fracture  through  the  anatomic  neck  in  adults.  ^  This 
fracture  should  be  treated  by  immobiHzation  for  a  varying  time- 
three  to  six  weeks.  If  the  head  of  the  bone  be  not  dislocated  from  its 
socket,  an  extremely  simple  apparatus  will  suffice— a  proper  pad  in  the 
axilla  to  hold  the  shaft  away  from  the  side,  and  a  firmly  applied  Velpeau 
bandage  making  snug  the  fragments.     If  there  be  marked  and  irreduci- 


Fig.  555. — Examination  of 
shoulder.  Method  of  palpat- 
ing head  of  humerus  with 
thumb  and  fingers.  Elbow 
grasped  by  other  hand  (.Scud- 
der). 


872  MINOR    SURGERY — DISEASES    OF    STRL'CTURE 

ble  cUsplacoment  of  the  shaft,  however,  especially  if  the  head  of  the 
bone  be  dislocated,  open  treatment  is  necessary.  In  operating  one 
may  be  obliged  to  remove  the  head  of  the  bone  entirely,  or  simply  to 
divide  or  displace  the  parts  preventing  reduction;  and  it  is  never  pos- 
sible before  operating  to  foretell  just  which  procedure  will  be  necessary. 
We  see,  therefore,  that  fractures  of  the  anatomic  neck  offer  a  wide 
range  of  possibility  as  regards  the  outcome  of  the  injury.  In  simple 
cases  we  may  look  for  a  perfect  restoration  of  function.  In  the  more 
complicated  and  difficult  cases  we  must  forecast  nothing  better  than  a 
permanently  stiffenetl  shoultler,  with  a  marked  diminution  in  the  arc  of 
motion. 


Fig.  556. — Examination  of  shoulder.     Movements  of  the  shoulder.     Normal  maxi- 
mum abduction.     Notice  method  of  grasping  head  of  humerus  (Scudder). 

Fracture  of  the  surgical  neck  of  the  humerus  means  properly  any 
fracture  below  the  epiphyseal  line  and  within  the  upper  fourth  of  the 
shaft  of  the  bone.  This  is  a  common  fracture  and  is  seen  at  all  ages. 
The  head  of  the  bone  rests  in  its  socket,  movements  are  painful,  crepitus 
is  present,  and  there  is  abnormal  mobility,  while  the  arm  is  distinctly 
shortened,  as  shown  by  measuring  the  shaft  from  the  acromion  process 
to  the  external  condyle  of  the  humeiais. 

In  the  case  of  children,  subperiosteal  fractures  of  the  surgical  neck 
are  not  uncommon.  Such  fractures  cannot  be  diagnosticated  without 
the  aid  of  the  x-ray. 

Fractures  of  the  surgical  neck  of  the  humerus  are  not  easy  of  treat- 
ment,  for  approximation   of   the   fragments   is   difficult   to   maintain. 


SPECIAL    FKACTURES    AND    THEIU   TREATMENT 


873 


Fig.  557. — Examination  of  shoulder.  Maximum  adduction.  The  bend  of  the 
elbow,  when  the  forearm  is  flexed  to  a  right  angle,  comes  to  the  median  Une  of  trtink 
(Scudder). 


Fig.  558. — Outline  of  shoulder  in  case  of  fracture  of  clavicle. 

We  have  taught  ourselves  to  beheve  that  traction,   countertraction, 
and  manipulation  will  secure  coaptation  of  the  fragments.     Sometimes 


874  IVIINOIt    SURGERY — DISEASES    OF    STRUCTURE 

we  are  justified  in  our  faith,  hut  at  the  best  it  is  hard  or  impossible  to 
hold  the  fragments  in  position.  The  following  method  has  long  been 
in  use  at  the  Massachusetts  General  Hospital  and  produces  a  fairly 
satisfactory  result:  The  hand,  forearm,  and  elbow  are  bandaged  firmly; 
a  V-shaped  pad  (with  the  apex  of  the  V  ii^  the  axilla)  constructed  of 
sheet-wadding  is  fitted  beneath  the  arm ;  and  a  shoulder-cap  of  wire  or 
plaster  of  Paris  is  fitted  over  the  whole  shoulder  and  down  the  aiTn  to 
the  external  condyle  of  the  lumierus.  The  arm  is  then  bandaged 
firmly  to  the  side  and  the  forearm  is  hung  in  a  sling. 

Other  similar  methods  are  sometimes  more  effective,  though  they 
may  be  cumbersome  and  expensive. 


Fig.  559. — Fracture  of  the  upper  end  of  the  humerus.     Note  hand,  forearm,  and 
elbow  bandaged  evenly  and  without  compression;  axillary  pad  and  strap  (Scudder). 

Whatever  the  apparatus  used,  we  find  that  it  is  continually  difficult 
to  hold  the  fragments  in  place.  The  dressing  must  be  removed  fre- 
quently and  regularly — at  least  once  a  week — so  that  the  surgeon  may 
inspect  the  limb  and  correct  malposition,  if  possible.  He  must  look 
out  also  for  pressure  sores,  and  will  do  well  to  have  the  shoulder  and 
arm  massaged  each  time  the  arm  is  exposed.  At  the  end  of  two  or  three 
weeks  soft  union  should  take  place;  and  fairly  firm  union  in  from  four 
to  six  weeks. 

These  fractures  of  the  surgical  neck  are  excellent  examples  of  frac- 
tures suitable  for  the  open  treatment.  Delayed  union,  or  non-union,  is 
not  uncommon.  Perfect  apposition  without  operation  is  almost  impos- 
sible. I,  therefore,  recommend  wiring  the  bones  in  the  case  of  persons 
who  are  not  old  or  afflicted  with  any  serious  organic  disease. 


SPECIAL    FRACTURES    AND   THEIR   TREATMENT 


875 


Fracture  of  the  shaft  of  the  humerus  does  not  differ  greatly  from 
fracture  of  the  surgical  ueck,  except  that  obliciue  and  spiral  fractures 


Fig.  560. — Fracture  of  the  upper  end  or  shaft  of  the  humerus.  Posterior  view. 
Note  bandage  to  forearm  and  elbow;  axillary  pad  and  strap.  Note  shape  of  axillary 
pad  (Scudder). 


Fig.  561. — Fracture  at  upper  end  of  the  humerus.  Note  hand,  forearm,  and 
elbow  bandaged;  axillary  pad  and  strap,  plaster-of-Paris  shoulder-cap,  sling  (Scud- 
der). 


are  nearly  as  common  in  the  shaft  as  are  transverse  fractures.     I  my- 
self had  the  mortification  to  cause  a  spiral  fracture  of  the  humerus  in  an 


876  MINOR    SURGERY — DISEASES    OF    STRIJCTURE 

old  m:in  whoso  shouklor-j(jiiit  (li.slocution  1  endeavored  to  reduce  by 
Kocher's  method. 


Fig.  562. — Fracture  of  the  shaft  of  the  humerus.  Note  bandage  to  hand,  fore- 
arm, and  elbow;  axillary  pad  and  strap;  coaptation  splints  and  sling.  Bandage  does 
not  cover  fracture  (Scutlder). 


Fig.  563. — Fracture  of  the  shaft  of  the  humerus.  Note  bandage  to  hand,  fore- 
arm, and  elbow;  adhesive-plaster  swathe  holding  arm  upon  axillary  pad  and  cover- 
ing coaptation  splints.     Sling  (Scudder). 

One  should  not  fail  to  recognize  a  fracture  of  the  shaft  of  the  humerus. 
The  arm  is  shortened  and  is  limp;    there   is  abnormal  mobility;   there 


SPECIAL    FRACTURES    A.XD    THEIR    TlfHAT.MENT 


877 


are    i)aiu    aiul   swelling,    while    the    gentlest    mani{)ulati()n    discovers 
crepitus. 

Let  the  surgeon  bear  in  mind  the  possible  involvement  of  the  musculo- 
spiral  nerve  in  one  of  these  fractures.  The  nerve  may  become  included 
in  new-forming  callus,  or  it  may  be  pinched  between  bone  fragments. 
If  the  surgeon  has  reason  tO  believe  that  the  nerve  is  involved,  he 
should  cut  down  upon  the  fracture,  displace  the  nerve,  and  wire  the 
fragments. 

The  treatment  of  fracture  of  the  shaft  may  be  simple  and  success- 
ful or  may  be  difficidt  and  disappointing.  Let  the  .r-ra}-  deter- 
mine. Proper  treatment  is  quite  similar  to  that  I  have  described 
for  fracture  of  the  surgical  neck:  anes- 
thesia; a  proper  axillar}-  pad;  a  band- 
age to  the  forearm;  splints  carefully 
applied  about  the  seat  of  fracture;  a 
sling  and  a  confining  bandage. 

The  progress  of  the  case  should  be 
simple,  and  at  a  rate  quite  similar  to  that 
of  a  surgical-neck  fracture.  Be  on  the 
lookout,  however,  for  wrist -drop- — a  char- 
acteristic deformity  resulting  from  in- 
jury to  the  musculospiral  nerve.  In  the 
case  of  wrist-drop,  change  the  method  of 
treatment  to  the  open  method.  c-v.  ^^-r-  -  ., 

Fractures  of  the  Elbow 

Interesting  and  important  as  are 
humerus  fractures  of  the  shoulder  and 
shaft,  humerus  fractures  at  the  lower 
end  of  that  bone  are  even  more  im- 
portant and  difficult  of  treatment.  These 
low  fractures  of  the  humerus  are  so  fre- 
quenth'  associated  with  fractures  of  the 
ulna  and  radius  that  we  consider  this  group  of  lesions  under  the 
caption  fractures  of  the  elhoic. 

The  student  should  turn  to  the  bony  skeleton  and  study  again  the 
relations  of  the  parts  about  the  elbow-joint,  making  note  especially 
of  three  bony  points — the  external  condyle,  the  internal  condyle,  and 
the  olecranon  process.  These  are  the  bony  points  most  frequently 
fractured.  But  there  are  two  other  important  structures  which  often 
are  damaged — the  head  of  the  radius  and  the  coronoid  process  of  the 
ulna.  That  is  to  say,  we  have  in  the  elbow-joint  a  combination  of 
three  bones  ^^'ith  a  remarkable  variety  of  projections,  depressions,  and 
articular  surfaces.  The  elbow-joint  is  a  hinge-joint  of  extremely 
complex  mechanism.  It  is  a  most  useful  joint.  From  all  these  facts 
it  results  that  damage  by  fracture  about  the  elbow-joint  may  have  a 
far  more  crippling  effect  often  than  the  apparent  bone  lesions  might 


Fig.  564.  —  Sho^-ing  effect 
(bowing  outward)  of  too  sliort 
an  axillary  pad  upon  a  fracture 
of  the  shaft  of  the  humerus 
(.Scudder). 


878 


MINOR   SURGEHV— DISEASES   OF   STHUCTUKE 


lead  the  observer  to  expect.     Moreover,  these  various  Ixniy  points  tire 
associated  with  a  great  variety  of  muscles  which  tend  to  pull  the  frag- 


External  condyle - 


Radial  liead- 


nal  condyle 


Olecranon  process 
of  the  ulna 


Fig.  565. — Note  tlie  bony  relations  of  the  internal  and  external  condyles  of  the 
humerus  and  the  olecranon  process  of  the  ulna  in  complete  extension  of  the  forearm. 
The  three  points  are  almost  in  a  straight  line  (Scudder). 

ments  out  of  position  when  loosened  by  a  fracture.      Furthermore, 
damage  to  the  synovial  surfaces  frecjuently  results  in  painful  and  dis- 


Fig.  566. — Lo\verend  of 
humerus,  anterior  surface. 
Note  Unes  of  fracture  of 
internal  epicondyle  and  of 
fracture  of  external  con- 
dyle (Scudder). 


Fig.  567. — Lo\ver  end  of 
humerus,  anterior  surface. 
Note  lines  of  supracondy- 
loid  fracture  and  of  frac- 
ture of  internal  condyle 
(Scudder). 


Fig.  56(S. — Lower  end  of 
humerus,  anterior  siu-face. 
Note  lines  of  T-fracture 
(Scudder). 


abling  adhesions,  while  nearly  always  loosened  fragments,  sliding  out 
of  place  and  out  of  their  normal  relations,  tend  to  block  the  joint  and 
limit  its  proper  movements. 


SPECIAL   FRACTURES    AND  THEIR   TREATMENT  879 

AVe  must  be  caivful,  painstaking,  and  final  in  our  examination  of  a 
damaged  elbow-joint,  and  must  have  in  mind  a  definite  routine  while 
making  the  examination.  The  surgeon,  seated  before  the  patient,  seizes 
the  hand  of  the  injured  ai'm  in  his  own  corresponding  hand  and  rests 
the  patient's  forearm  upon  his  own  other  forearm,  supporting  the 
damaged  elbow  with  his  hand.  The  surgeon's  fingers  supporting  the 
elbow  then  investigate  the  following  bony  points:  the  internal  condyle, 
the  external  condyle,  the  olecranon,  the  head  of  the  radius,  and  the 
coronoid  process.  The  surgeon  then  gently  puts  the  injured  arm 
through  the  motions  of  flexion,  extension,  and  rotation.  If  there  be 
great  swelling  of  the  elbow  or  great  pain  on  manipulation,  the  patient 
should  be  anesthetized.  Indeed,  it  happens  commonly  that  anesthesia 
is  useful  as  an  aid  in  the  proper  reduction  of  the  fracture.  Finally,  two 
or  more  x-ray  plates,  taken  in  different  planes,  are  necessary  accurately 
to  elucidate  the  details  of  the  fracture.  There  is  an  excellent  old 
maxim  that  in  reducing  one  of  these  fractures  the  surgeon  should  go 
through  the  movements  of  reducing  a  dislocation  backward  of  the 
elbow.  Indeed,  great  swelling  mav  mask  a  dislocation,  while  at  the 
same  time  a  fracture  and  a  dislocation  may  coexist. 

The  details  of  these  fractures  are  as  follows: 

Lesions  of  the  Lower  End  of  the  Humerus  : 
(a)  Fracture  of  the  internal  epicondyle. 
(6)   Fracture  of  the  internal  condyle. 

(c)  Fracture  of  the  external  condyle. 

(d)  Transverse  fracture  of  the  shaft  of  the  humerus  above  the  con- 
dyles. 

(e)  Separation  of  the  lower  epiphysis  of  the  humerus. 
(J')    T-fracture  into  the  elbow-joint. 

Lesions  of  the  Radius  and  Ulna  : 

(g)  Dislocation  of  the  radius  and  ulna  backward  wdth  or  without 
fracture  of  the  coronoid  process  of  the  ulna. 

(h)  Subluxation  of  the  head  of  the  radius. 

(i)    Fracture  of  the  olecranon  process  of  the  ulna. 

(/)  Fracture  of  the  neck  or  head  of  the  radius. 

Besides  these  fractures,  which  appear  frankly  as  fractures  in  adult 
bones,  there  are  the  corresponding  fractures  in  the  forming  bones  of 
children. 

The  treatment  of  these  lesions  about  the  elbow-joint  taxes  the  ingenu- 
ity of  the  surgeon,  and  frequently  proves  extremely  discouraging.  We 
endeavor  to  bring  the  fragments  into  apposition,  and  we  attempt  to 
secure  union  without  a  coincident  impairment  of  motion. 

It  is  true,  as  Scudder  states,  that  the  object  of  treatment  is  to  restore 
the  elbow-joint  to  its  normal  condition;  but  I  should  qualify  that  bj^  sav- 
ing the  object  of  treatment  is  to  restore  the  elbow-joint  to  usefulness.  It 
is  by  no  means  always  possible  to  restore  the  joint  to  its  normal  condi- 
tion; but  generally  it  is  possible,  in  spite  of  extreme  damage  and  loss 
of  bone  substance  even,  to  bring  out  a  useful  joint. 


880  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

At  first,  and  so  long  as  ^roat  swelling  persists,  we  can  do  little  more 
than  keep  the  elbow  comfortably  at  rest  on  a  pillow.  When  the  swelling 
has  subsided,  we  should  put  up  the  arm  in  a  permanent  dressing.  We 
must  not  long  delay  this  dressing,  for  ossification  about  the  elbow- 
joint  proceeds  with  gn>at  rapidit}-. 

We  should  treat  fractures  of  the  internal  epicondyle,  of  the 
internal  condyle,  of  the  external  condyle,  and  T-fractures  into 
the  joint  in  the  acutely  flexed  position.  H.  L.  Smith,  of  the  Boston 
City  Hospital,  was  the  first  surgeon  to  demonstrate  the  value  of  the 
acutely  flexed  position,'  and  a  wide  experience  of  many  surgeons  has 
shown  that  this  position  actually  reduces  antl  holds  reduced  the  frac- 
tures we  are  discussing. 


^ 


Fig.  569. — Supracondyloid  fracture  of  tlic  liuincrus.  Method  of  reduction 
before  applying  retentive  splint.  Countertraction  on  upper  arm.  Traction  on 
condyles  of  humerus  with  right  hand;  backward  pressure  with  thumb  of  left  hand. 
Also  illustrative  of  method  of  beginning  acute  flexion  (Scudder). 

Says  Scudder  in  regard  to  method:  "The  condyles  of  the  humerus 
are  grasped  by  the  thumb  and  finger  of  one  hand;  a  finger  of  the  other 
hand  is  placed  in  the  bend  of  the  elbow\  Traction  is  made  upon  the 
forearm,  and  it  is  slowly  flexed  to  an  acute  angle.  While  the  for(>arm 
is  being  flexed,  traction  and  lateral  pressure  are  brought  to  bear  tipon 
the  loose  fragments  of  the  humerus,  to  correct  existing  malposition." 
The  degree  of  flexion  will  be  determined  by  the  obstruction  offered 
by  the  local  swelling.  This  acutely  flexed  position  is  maintained  by  an 
adhesive-plaster  strap.  There  are  certain  precautions  to  be  taken  and 
dangers  to  be  avoided  in  our  use  of  the  acutely  flexed  position;  especi- 
ally must  we  inspect  daily  the  arm  during  the  first  week,  and  we  must 
see  to  it  that  proper  circulation  is  maintained  in  the  hand.     At  the 

1  H.  L.  Smith,  Position  in  the  Treatment  of  Elbow-joint  Fractures,  Boston  Med- 
and  Surg.  Jour.,  October  18,  1894. 


SPECIAL    FHACTUKES   AND   THEIR   TREATMENT 


881 


end  of  three  weeks,  in  the  average  case,  we  can  begin  passive  motions 
with  the  damaged  elbow;  we  have  secured  good  fiexion  and  even  if 
perfect  extension  is  not  obtained,  the  imperfect  extension  will  be  a  less 
serious  disadvantage  to  the  patient  than  would  be  inadequate  flexion. 
Transverse  fracture  of  the  humerus  above  the  condyles  is  an 
ugly  fi-acture,  and  difficult  to  fix,  for  there  is  a  constant  tendency  of 
the  lower  fragment  to  slip  backward,  and  thus  to  produce  a  deformity 
which  resembles  a  backward  dislocation  of  the  bones  of  the  forearm. 
This  low  fracture  of  the  humerus  is  fairly  well  held  in  place  by  the 


_  Fig.  570.— Left  elbow  in  position  of  forced  flexion.  Gauze  in  bend  of  elbow. 
Thin  axillary  pad.  Pad  under  hand  and  wrist.  Gauze  protection  under  forearm, 
held  by  safety-pin  from  sHpping.  Adhesive  plaster  maintaining  flexion.  Skin  pro- 
tected on  upper  arm  by  gauze  compress  from  cutting  of  adhesive  plaster  (Scudder). 

internal  angular  splint,  such  as  the  illustration- shows.  This  splint 
must  be  padded  carefully  and  must  be  strapped  with  two  straps  upon 
the  forearm  and  two  above  the  elbow,  that  it  may  be  held  absolutely 
without  shifting.  The  outlook  and  rate  of  healing  in  these  low  fractures 
of  the  humeral  shaft  are  quite  similar  to  the  outlook  and  rate  of  healing 
of  higher  fractures  of  the  humerus. 

A  dislocation  backward  of  both  bones  of  the  forearm  is  easily 
reduced  when  the  patient  is  anesthetized ;  and  the  replaced  bones  may 
be  held  comfortably  in  position  on  the  internal  angular  splint. 

Fracture  of  the  neck  of  the  radius  is  best  treated  by  support  on 
the  internal  angular  splint. 

56 


882 


MINOR    SURC.EUY— DISEASES    OF    STRUCTURE 


Fracture  of  the  olecranon  produces  a  situation,  and  calls  for  the 
solution  of  a  problem,  of  a  new  type.     Integrity  of  the  olecranon  is 


Fig.  571. — Supracondyloid  fracture. 
Obliquity  of  the  line  of  fracture  from  be- 
hind downward  and  forward.  Diagram 
showing  deformity  with  elbow  flexed  and 
little  sliding  of  fragments  (Scudder). 


Fig.  572. — Supracondyloid  fracture. 
Obliquity  of  the  hne  of  fracture  from 
above  downward  and  backward.  Dia- 
gram showing  tendency  to  posterior  de- 
formity if  acute  flexion  of  forearm  is 
attempted  (Scudder). 


r 


'^. 


essential  to  the  strong  and  proper  extension  of  the  forearm ;  the  elbow 
fractures  we  have  discussed  hitherto  interfere  with  proper  flexion 
mainly.      In  these  cases  we  have  seen  that  a  restoration  of  flexion  is 

sought,  but  a  dressing  of  the  elbow 
in  a  flexed  position  is  not  suitable 
for  a  fracture  which  involves  impair- 
ment of  proper  extension. 

We  recall  the  fact  that  the  bra- 

chialis  anticus  muscle  is  inserted  into 

the  base  of  the  coronoid  process  of  the 

,^^..      ulna;  that  the  triceps  muscle  is  in- 

tm^ """•^i^'^ '  '^m        serted  into  the  posterior  part  of  the 

upper  surface  of  the  olecranon  and 
into  the  fascia  of  the  posterior  surface 
of  the  forearm,  and  that  the  small 
epiphyses  of  the  olecranon  unite  with 
the  shaft  about  the  sixteenth  year. 

The  olecranon   is   usually  bi'oken 
by    great    violence,    and    at  a  point 
from    one    to    two    inches   from    its 
tip.     Thus  the  elbow-joint  is  always 
opened  when  the  olecranon  is  frac- 
tured.    Sometimes  there  is  a  marked 
defoimity  and  a  depression  between  the  bone  fragments,  into  which 
depression  one's  examining  finger  sinks;    or  there  may  be  little  or  no 
separation  of  fragments. 


Fig.  57.3. — Third  strap  is  necessary 
to  hold  the  splint  close  to  the  flexed 
elbow  (vScudder). 


SPECIAL    FKACTLKES    AND    THKIK    TREATMENT  883 

The  treatment  of  an  olecranon  fracture  depends  somewhat  upon  the 
extent  of  separation  of  the  fragments.  If  the  fragments  He  close 
together,  the  arm  may  be  dressed  satisfactorily,  and  most  comfortably 
for  the  patient,  in  the  right-angled  splint;  but  if  there  be  obvious 
separation,  the  arm  should  be  extended  straight  and  should  be  bound 
upon  a  long  splint  reaching  from  the  axilla  to  two  inches  beyond  the 
finger-tips;  while  the  small  upper  fragment  of  the  olecranon  should  be 
secured  and  held  down  in  place  by  a  special  adhesive  strap.  If  it  be 
found  impossible  by  this  means  to  bring  the  upper  fragment  into  proper 


Fig.  574. — Fracture  of  the  olecranon.     Arm  in  extension.     Long  anterior  splint. 
Note  pad  and  strap  above  olecranon  fragment;   pad  in  palm  of  hand  (Scudder). 

position,  the  surgeon  will  do  well  to  cut  dowm  upon  and  to  wire  the 
fragments.  If  the  fracture  is  a  compound  fracture,  the  surgeon  must 
take  special  pains  as  a  preliminary  step  thoroughly  to  disinfect  the 
elbows-joint,  after  w^hich  he  may  wire  the  fragments. 

Such  are  the  main  points  in  the  diagnosis  and  treatment  of  fractures 
about  the  elbow-joint. 

A  word  about  old  neglected  fractures  of  the  elbow-joint  or 
malunion  in  spite  of  treatment.  These  are  peculiarly  difficult  cases, 
which  fall  into  that  class  I  have  alread}^  described  as  calling  for  most 
careful  consideration  and  consultation  prior  to  any  radical  operation. 


884 


MINOR   SURGERY — DISEASES   OF   STRUCTURE 


The  classic  operation  for  old  crippling  deformities  of  the  elbow-joint 
(usually  ankylosis)  is  a  complete  excision  or  removal  of  the  joint  and 
adjacent  broken  bones.  This  leaves  the  patient  with  a  flail-joint,  but 
generally  with  a  strong  and  serviceable  arm.  Another  method  of 
operating  is  that  advocated  by  J,  B.  Murphy,  who  constructs  a  new 
joint  by  separating  the  fused  and  adherent  fragments  of  bone,  and 
then  interposing  between  them  strips  of  fascia  turned  down  from  the 
arm,  from  which  fascia  it  comes  about  that  there  develop  new  joint 
surfaces  resembling  synovial  surfaces.  Sometimes  the  joints  thus  formed 
are  but  little  inferior  to  normal  joints. 

Fractures  of  the  Bones  of  the  Forearm 

These  fractures  are  both  complete  and  incomplete — green-stick 
fractures  of  these  bones  are  not  uncommon  in  children.  Whatever 
the  nature  of  the  break,  the  arm  cannot  be  used  without  pain.  There 
may  be  considerable  bowing  and  deformity,  or  the  defoi-mit}'  may  be 
slight.     There  is  usuallv  some  shortening,  and  the  arm  hangs  flaccid 


Fig.  575. — Fracture  of  both  bones  of  the  forearm.  Ulnar  view  of  the  anterior 
and  posterior  splints.  Note  length  of  splints  and  position  of  straps.  Straps  of  the 
internal  right-angled  splint,  3  and  4  (Scudder). 

and  useless.  The  fracture  is  generally  either  in  the  middle  or  lower 
third  of  the  forearm,  while  if  both  bones  be  fractured,  the  break  in  the 
ulna  is  somewhat  lower  than  is  the  break  in  the  radius.  Crepitus  is 
usually  obvious  except  when  the  fracture  is  of  the  green-stick  variety. 
The  treatment  of  fractures  of  both  bones  of  the  forearm  is  more 
difficult  than  at  first  would  appear,  because  even  after  splints  are 
applied  the  pull  of  the  long  muscles  tends  constantly  to  cause  over- 
riding at  the  seat  of  fracture,  with  a  consequent  shortening.  At  the 
same  time  there  is  apt  to  result  delayed  union  or  non-union;  while 
the  displacement  of  the  fr^^ments  narr-^ws  the  interosseous  space  and 


SPECIAL    FllAfTURES    AND    THEIR    TREATMENT  885 

may  result  in  a  fusing  together  even  of  all  fou]-  of  the  fragments;  so 
that  subsequent  rotation  of  the  arm  becomes  impossible,  and  the 
usefulness  of  that  limb  is  greatly  impaired. 

Green-stick  fractures  cannot  be  straightened  successfully.  Such  frac- 
tures must  be  made  complete  fractures  by  the  surgeon,  ^vho  accomplishes 
this  by  bending  the  arm  in  the  direction  of  the  original  breaking  force. 

For  fractures  of  both  bones  of  the  forearm  we  may  use  a  plaster- 
of-Paris  bandage  or  anterior  and  posterior  splints.  Commonly,  the 
patient  should  be  anesthetized,  and  painstaking  care  must  be  employed 
to  insure  perfect  bone  apposition  through  traction  upon  the  lower 
fragments.      The  arm  should    be    put  up  in  a  supinated  position,  as 


Fig.  576. — Fracture  of  both  bones  of  the  forearm.  Proper  position  of  arm  in 
sling.  Note  hand  is  unsupported  by  sling  and  arm  rests  on  ulnar  side.  Xotice 
height  of  arm  (Scudder). 

thus  the  greatest  space  between  the  bones  is  maintained.  In  order 
to  secure  a  proper  fixing  of  the  fragments  in  one  of  these  fractures  the 
adjacent  joints  also  must  be  immobilized— the  elbow  by  an  internal 
angular  splint  or  by  plaster,  and  the  wrist  by  anterior  and  posterior 
splints  or  by  plaster.  I  prefer  to  use  the  right-angled  and  wooden 
splints  for  the  first  ten  days  after  the  injury.  Such  splints  can  be 
removed  more  readily  for  inspection  of  the  arm  than  can  plaster-of- 
Paris  splints.  The  healing  of  properly  treated  bones  of  the  forearm 
is  rapid.  Adult  bones  are  sound  in  about  four  weeks.  The  bones  of 
children  are  often  sound  in  two  weeks;  but  children  should  not  then 
be  released  from  splints,  for  they  may  refracture  their  bones  at  the  seat 
of  the  fresh  union. 


886  MINOR    SURGERY — DISEASES    OF    STRUCTURE 

A  fracture  of  the  shaft  of  o)ic  of  the  forearm  bones  only  is  easily 
treated,  and  on  lines  laid  down  in  the  preceding  paragraphs.  When 
one  bone  only  is  broken,  its  intact  fellow  serves  as  an  additional  splint. 

Non-union  of  bones  of  the  forearm  is  fairly  conimon. 

Fracture  of  the  head  and  neck  of  the  radius  is  recognized  to-day 
as  a  not  infrecjuent  injury.  The  x-ray  shows  it,  though  it  is  obscure 
to  the  surgeon's  touch.  Fracture  of  the  head  alone  is  intracapsular. 
The  fragments  may  remain  in  place,  or  may  be  crowded  into  a  remote 
part  of  the  joint,  where  they  must  be  sought  and  removed  with  difiicidty 
through  operation  by  the  open  method. 

Treat  this  fracture  of  the  radius  head,  if  simple  and  not  complicated, 
by  fixation  in  a  right-angled  splint,  and  look  for  prompt  union  with  a 
useful  joint. 

Fracture  of  the  coronoid  process  of  the  ulna  is  associated  with 
a  backward  dislocation  of  the  uhia,  and  is  rare.  Suspect  the  presence 
of  this  fracture  in  every  case  of  dislocation  backward  of  the  elbow,  and 
confirm  the  diagnosis  by  the  .r-ray.  This  coronoid  fracture  may  prove 
extremely  troublesome.  If.  the  displacement  be  slight,  the  position 
good,  and  flexion  satisfactory,  we  may  look  for  prompt  union  and  a 
useful  elbow  through  the  employment  of  the  right-angled  splint.  If 
there  be  considerable  displacement  and  locking  of  the  joint  by  the 
fragment,  we  must  open  down  upon  the  bone  and  remove  the  frag- 
ment. 

CoLLES'  Fracture 

Colles'  fracture  was  described  first  by  Abram  Colles  more  than  one 
hundred  years  ago.  The  fracture  of  which  Colles  wrote  was  a  fracture 
of  the  radius  within  an  inch  and  a  half  of  its  lower  end — a  fracture  loose 


Fig.  .577. — Colles'  fracture.     Note  "silver-fork"  deformity. 

or  impacted,  and  characterized  by  the  so-called  silver-fork  deformity. 
It  must  not  be  confounded  with  the  Barton  fracture,  in  which  case 
the  deformity  is  the  reverse  of  the  Colles,  the  forearm  bones  riding 
over  the  carpus  instead  of  under  the  carpus,  as  in  Colles'  fracture. 

Of  recent  years  a  variety  of  fractures  concerned  wuth  the  bones  of 
the  carpus  have  been  studied — fractures  which,  before  the  day  of  the 
x-ray,  frequently  were  mistaken  for  Colles'  fractures.    As  Scudder  insists, 


SPECIAL    FKACTUKES    AND   THEIK    TREATMENT 


887 


in  nil  cases  of  cUmiagc  to  the  wrist  the  surgeon  should  first  study  care- 
fully the  uninjuretl  wrist,  that  he  may  compare  it  with  its  damaged 
fellow.  We  must  remember  that  normally,  when  viewing  the  wrist 
from  the  front,  we  see  the  base  of  the  thenar  eminence  to  be  lower  than 
the  base  of  the  hypothenar.  Normally,  the  styloid  process  of  the  ulna 
is  obvious  with  the  marked  depression  below  it;  while  on  the  radial 
side  one  observes  the  backward  curve  of  the  radial  shaft  from  the 


./ 


Fig.  578. — Colles'  fracture.     Crowding  the  fragments  together  for  diagnosis. 

point  where  the  radial  styloid  joins  the  shaft.  One  should  put  the 
patient  through  the  normal  movements  of  the  hands,  wrist,  and  arm, 
flexion,  extension,  and  rotation. 

Then  we  observe  the  abnormalities  of  the  damaged  arm;  the  wrist 
appears  unnatural;  in  extreme  cases  we  may  see  at  once  the  familiar 
silver-fork  deformity;  the  thenar  eminence  is  higher  and  nearer  to 
the  wrist  than  normal.  The  whole  hand  is  somewhat  abducted  and 
the  styloid  process  of  the  radius  is  no  longer  found  on  a  level  lower  than 


888 


MINOR   SURGERY — DISEASES    OF    STRUCTURK 


the  styloid  of  the  uhia,  but  at  the  same  level  or  at  a  higher  level  even. 
Sometimes  the  ulnar  styloiil  is  fractured,  in  Avhich  case  the  i-elation  of 
these  two  points  appears  normal. 

One  may  often  elicit  pain  l\v  palpating  the  end  of  the  radius.  In 
case  of  a  doubtful  fracture^  an  excellent  test  is  to  seize  the  patient's 
hand,  and,  while  supporting  his  arm  above,  to  crowd  the  hand  gently 


Fig.  579. — Dorsal  dislocation  of  the  wrist.    Note  deformity  at  wrist-joint — neither 
above  nor  below  it  (after  Helferich)  (Scudder). 

upward.  This  invariably  will  bring  out  a  point  of  pain  near  the  lower 
end  of  the  radius  if  a  fracture  exists.  If  there  be  a  sprain  merely, 
this  crowding  upward  of  the  hand  gives  relief  rather  than  pain.  In 
Colles'  fracture  the  fragments  may  be  impacted  or  may  be  loose;  and 
the  exact  condition  of  the  radius,  as  well  as  of  the  other  bones  about 
the  wrist,  is  faithfully  demonstrated  by  the  x-ra3^ 


Fig.  .580. — Dorsal  dislocation  of  the  hand  at  carpometacarpal  joints.     Note  deformity 
below  wrist  (after  Helferich)  (Scudder). 


Dislocation  of  the  wrist  must  not  be  mistaken  for  a  Colles  fracture. 
A  fracture  of  both  the  forearm  bones  near  the  wrist  appears  as  an 
exaggerated  Colles',  but  the  crepitus  of  the  two  bones  readily  is  dis- 
covered. In  persons  under  twenty-one  years  of  age  separation  of  the 
lower  epiphysis  of  the  radius  simulates  a  Colles  fracture.     The  damage 


SPECIAL    FRACTURES    AND    THEIR   TREATMENT 


889 


is  less  grave  generally  than  is  a  Colles  fracture,  although  the  treatment 
of  the  two  conditions  may  be  similar.^ 

The  treatment  of  Colles'  fracture  has  been  a  subject  of  interest 
and  controversy  for  one  hundred  years.     A  broken  wrist  is  a  serious 


Fig.  581.— E.  M.  Moore's  dressing  for  Colles'  fracture. 

matter,  for  though  the  bones  may  unite  well,  they  may  not  unite  accur- 
ately, so  that  the  resulting  malunion  causes  stiffness  of  the  wrist,  inter- 


Fig.  582.— vReduction  of  Colles'  fracture.     Note  position  of  hands  in  forcibly  hyper- 
extending  the  lower  fragment;   breaking  up  impaction  (Scudder). 

ference  with  the  motions  of  the  tendons  and  joint  surfaces,  and  a  distress- 
ing and  permanent  crippling  of  the  hand.      One's  endeavor  then  is 

1  E.  M.  Moore  taught  correctly,  forty  years  ago,  that  a  displaced  radial  epiphysis, 
after  reduction,  is  successfully  and  easily  treated  by  wrapping  a  single  two-inch 
strip  of  adhesive  plaster  about  the  wrist — not  overlapping  it  on  the  ulnar  side;  the 
arm  is  then  supported  in  a  narrow  sling  bandage.  The  hand  naturally  falls  toward 
the  ulna,  and  maintains  the  bones  in  position.  I  have  employed  Moore's  method 
with  satisfaction. 


890 


MINOR   SURGERY — DISEASES   OF   STRUCTURE 


carefully  to  reduce  the  fracture,  breaking  vp  the  imfaction  if  one  exists, 
to  secure  the  fragments  properly  immobilized,  and  finally^ — a  matter 
of  the  greatest  importance — to  relieve  the  hand  of  the  confining  splints 
at  the  earliest  possible  moment  consistent  with  fixation  of  the  fi-agments. 
We  anesthetize  the  patient;  we  drag  down  the  hand,  turning  it  slightly 
into  abduction  (or  ulnar  flexion),  carefully  mold  the  bones  into  position, 
and  fix  the  parts  firmly  in  two  splints,  as  the  figure  illustrates. 


Fig.  583. — Reduction  of  Colles'  fracture.  Nf>tf  gras|)  upon  forearm  and  the  lower 
fragment  of  tlie  radius,  traction  and  countertraction  being  made;  breaking  up  the 
impaction  (Scudder). 

An  interesting  and  important  consideration  in  the  treatment  of 
Colles'  fracture  is  the  care  of  the  hand  during  the  two  or  three  weeks 
of  convalescence.  Union  is  almost  always  prompt,  and  displacement 
of  the  fragments  after  a  week  is  extremely  improbable.  For  this  reason 
we  may  begin  early  the  gradual  removal  of  splints,  lightening  the 
apparatus  and  employing  massage.     After  one  week  I  get  rid  of  the 


Pig.  .584. — Reduction  of  Colles'  fracture.  Note  position  of  the  thumbs  and 
fingers.  Lower  fragment  is  pushed  into  place,  while  counterpressure  is  made  by  the 
fingers  upon  the  upper  fragment  (Scudder). 

anterior  splint,  and  hold  the  hand  in  a  single  posterior  splint  during 
the  second  week.  At  the  end  of  this  fortnight  the  posterior  splint  is 
removed,  and  a  short  dorsal  splint,  with  an  anterior  pad.  is  secured  upon 
the  wrist,  which  is  hung  in  a  narrow  sling.  This  splint  in  turn  may 
generally  be  renewed  at  the  end  of  the  third  week,  when  systematic, 
skilful  daily  massage  of  the  arm,  elbow,  WTist,  and  hand  is  begun,  and 


SPECIAL   FRACTURES   AND   THEIR  TREATMENT  891 

is'  continued  until  the  puticnt's  strength  is  restored.  We  encourage 
a  noi-mal  use  of  the  released  fingers  in  the  second  week,  or  as  soon  as  the 
first  heavy  dressing  is  removed. 

Old  Colles'  fractures,  neglected  and  badly  united,  offer  a  serious 
problem  to  the  surgeon.  If  the  patient  be  young  and  vigorous,  an 
operation  may  give  him  a  useful  hand.     If  the  patient  be  old  and  the 


jTjo-  585. — Fracture  o  tne  forearm  near  the  wrist-joint.  Notice  wrinkles  m  the 
straps"  The  straps  are  loose  from  the  pressure  of  the  two  splints  together.  Thus 
is  illustrated  the  fact  that  the  straps  should  retain  splints  m  position  without  ex- 
erting much  pressure  (Scudder). 

injury  of  long  standing,  we  may  be  able  to  do  little  more  than  relieve 
the  pain  and  correct  deformity.  H.  A.  Lothrop  describes  a_  useful 
operative  technic :  ^  Approach  the  damaged  bone  from  the  radial  side 
and  isolate  the  soft  parts;  with  a  small  drill  perforate  the  bone  at 
several  points  in  the  line  of  union,  and  complete  the  new  fracture  with 
a  chisel.  Then  trim  off  the  fragments  and  approximate  them  carefully. 
If  the  ulna  is  so  long  as  to  interfere  with  correction  of  the  deformity, 


Fig.  586.— Posterior  spUnt,  three  straps,  and  pad  at  the  seat  of  fracture.     Note  com- 
fortable position  of  forearm  and  hand  (Scudder). 


that  bone  may  be  shortened  by  excising  a  small  section  about  two  inches 
from  the  joint.  Then  reduce  and  fix  the  fragments  in  the  usual  manner 
after  having  closed  the  wound,  and  treat  the  case  as  an  ordinary 
fracture  of  both  bones  of  the  wrist. 

Fractures  of  the  Carpus 

Fractures  of  the  carpus  are  frequently  mistaken  for  sprained  wrist 
or  for  Colles'  fractures  even.     Now  that  we  have  the  x-ray,  such  mis- 
1  Quoted  by  C.  L.  Scudder,  ibid. 


892 


MINOR    SUUGEKY — DISEASES    OF    STRUCTURE 


tukt's  should  never  i)e  made.  Damage  to  the  carpus  occuis  commoiil'J 
from  ii  fall  upon  the  extentled  hanil.  It  may  l)e  that  some  of  thd 
smaller  bones  of  the  carpus  thus  become  dislocated,  but  the  conmion 
carpal  injury  is  a  fracture  of  the  scaphoid.  Our  x-ray  tracing  shows 
how  the  scaphoid  lies  against  the  articulating  surface  of  the  radius, 
and  thus  takes  the  weight  of  the  body  in  the  case  of  a  fall. 

Surgeons  see  two  types  of  scaphoid  fracture — the  acute  and  the 
chronic  type.  The  acute  fracture  causes  pain  and  tenderness  in  the 
wrist,  over  the  scaphoid,  together  with  swelling,  spasm,  and  a  loss  of 
function.  If  we  ascertain  the  nature  of  the  damage  at  once,  we  may 
correct  it  by  fixing  the  hand  in  a  splint  for  two  or  three  weeks;  and 
we  follow  up  this  treatment  by  active  and  passive  movements  and  by 
massage. 

The  chronic  cases  are  brought  to  the  surgeon  because  of  a  long- 
standing weakness  of    the  patient's  wrist  and  pain  when  his  hand  is 


—  Soaphoid  fragment 

—  "  Scaphoid  Jragment 

— i- Radial  fissure 


Fig.   587.— Case.     Fracture  of  the  scaphoid  and  fissure  of  radius   (.r-ray  tracing) 

(Balch)  (Scudder). 

overextended.  In  such  cases  one  finds  the  wrist  movements  to  be 
limited,  and  spasm  to  be  present  in  the  extreme  of  motion.  There 
are  swelling  on  the  radial  sitle  and  tenderness  over  the  scaphoid,  while 
the  x-ray  discovers  a  fracture,  usiuilly  transverse,  across  the  bone. 

E.  A.  Codman  has  worked  out  the  proper  treatment  for  these  cases. 
If  rest  and  massage  do  not  improve  the  condition,  cut  doAAii  upon  the 
scaphoid  from  behind  and  remove  the  smaller  fragments  of  bone.  One 
should  not  remove  the  whole  bone  if  such  removal  can  be  avoided,  for 
loss  of  the  whole  scaphoid  leaves  the  wrist  permanently  weak. 


Fracture  of  the  Metacarpal  Bones 

The  third  and  fourth  metacarpal  bones  are  the  metacarpals  com- 
monly broken,  and  they   are  broken  by  indirect  violence  usually,  a 


SPECIAI.    FllACrrUUES   AND   THEIR   TllEATMENT 


893 


blow  upon  the  knuckles,  such  us  may  happen  through  a  straight  thrust 
in  sparrhi"-  There  is  a  characteristic  deformity,  as  the  photographs 
show  The  dorsum  of  the  hand  is  swollen,  and  the  knuckle  ot  the 
damaged  bone  is  sunken,  while  the  end  of  the  lower  fragment  otten 


A  B 

!?,•„  '^ss  A  Fracture  of  neck  of  fourth  metacarpal  bone.  Swelling  of  finger 
and  t"ucM'-"ltSkthS  Ipped  downward  toward  the  palm.  B,  Normal  hand. 
Line  of  knuckles  shown.     Contrast  with  A  (Scudder). 

can  be  felt  in  the  palm,  and  there  is  pain,  with  crepitus.     Do  not  mis- 
take this  iniurv  for  a  dislocation. 

It  is  not  aLays  easy  successfully  to  treat  a  fractured  metacarpal. 
We  reduce  the  fracture  by  traction  and  pressure,  and  support  the 
hand  and  forearm  upon  an  anterior  splint,  with  a  pad  m  the  palm  of 


the  hand  and  a  pad  over  the  dorsum.  If  this  apparatus  does  not 
hold  the  fragments  in  position  it  may  be  well  to  employ  a  simp  e 
traction  apparatus  with  adhesive  straps  and  rubber  tubing  as  the  ut 
illustrates  Fracture  of  the  second  metacarpal  may  be  well  treated 
by  binding  the  finger  over  a  roller  bandage. 


894 


MIXOK    SUUGEKY — DISEASES    OF    STRUCTURE 


Bennett's  Fracture} — In  1881  E.  H.  Bennett,  of  Du))lin,  described  a 
peculiar  fracture  of  the  metacarpal  of  the  thumb. 

This  fracture  has  come  to  be  known  as  "stave"  of  the  thumb. 
It  is  a  fracture  of  the  proximal  end  of  the  bone;  oblique  and  into  the 
trapezium  joint.     The  metacarpal   bone  is  disphiced   backward,   and 


1^.  .I'.Hi.  -  I'raftun-  of  tin-  in-ck  of  tli<.'  mtdihI  iiiciacaijial.  .Mi-i!,(.ii  (,\  M-cuiing 
extension.  Xote  adhesive  plaster,  rubber  tubing,  peg,  padding  to  tinger,  pad  over 
proximal  fragment.  Coimterextension  by  adhesive  plaster  about  wrist.  Ready  for 
the  application  of  a  bandage  (Scudder). 

the  fracture  may  well  be  mistaken  for  a  dislocation  at  this  joint.  Some- 
times the  fracture  through  the  bone  is  transverse  mereh'  and  does  not 
open  the  joint.  For  such  a  simple  case  any  immobilizing  apparatus 
will  sufhce.     Samuel  Robinson  describes  a  useful  device  for  correcting 


Fig.    501.— Fracture    of   the    finger.  Fig.  592. — Finger  sphnt  of  copper 

Wooden  splint  apphed  to  the  palmar  sur-  wire  applied  (Scudder) 
face.     Note  straps  and  length  of  splint 
(Scudder). 

and  holding  the  worst  form  of  the  Bennett  fracture — an  apparatus  of 
plaster  of  Paris,  combined  with  extension  and  side  splints.  The 
apparatus  should  remain  in  place  for  about  two  weeks. 

^Samuel  Robinson.  The  Bennett  Fracture  of  the  First  Metacarpal  Bone.  Diag- 
nosis and  Treatment,  Boston  Med.  and  Surg.  Jour.,  February',  27.  1908 


SPECIAL   FllACTUHES    AND   THEIR   TREATMENT 


895 


Phalanges 

Fracture  of  the  phalanges  is  so  apparent  that  it  scarcely  needs 
desciiption;  though  occasionally  the  fracture  may  be  a  mere  crack, 
when  the  a--ray  alone  can  demonstrate  it.  Ordinarily,  however,  the 
bones,  lying  close  under  the  skin,  may  easily  be  palpated. 

In  the  treatment  of  these  phalanx  fractures  one  must  take  every  pains 
to  see  that  the  delicate  and  important  mechanism  of  the  fingers  be  not 
seriously  disturbed.  A  perfect  alignment  of  the  fragments  must  be 
maintained,  and,  as  Scudder  says,  rotation  of  the  lower  fragments  upon 
its  long  axis  must  be  guarded  against.  In  case  of  great  swelling  a 
temporary  dressing  upon  a  long  palmar  splint  will  suffice,  but  when 
the  swelling  has  subsided  the  surgeon  must  apply  carefully  a  small 


Fig.  593. 


-Palmar  wooden  thumb  splint      Note  shape,  pads,  straps,  position 
(Scudder), 


well-fitting  splint  of  tin  or  wood.     Fractured  phalanges  unite  in  two 
or  three  weeks. 

Compound  fractures  of  the  phalanges  sometimes  become  infected  and 
lead  to  extensive  suppuration  with  destruction  of  bones.  Healing 
eventually  will  take  place  under  antiseptic  dressings  and  splinting, 
but  the  affected  finger  will  almost  surely  be  stiff.  In  such  a  case  a 
patient  may  choose  to  have  his  finger  amputated. 


Femur 

Fractures  of  the  femur  are  various  in  character  and  in  location, 
and  are  difficult  of  treatment.  Fracture  of  the  femur  is  the  pons 
asinoruvi   of  the  surgical  tyro.     The  complicated  upper  end  of  the 


896 


MINOR    SURGERY — DISEASES    OF    STRLCTUKE 


femur  is  the  part  most  frequently  broken,  while  its  close  relationship 
to  the  hip-joint  renders  its  proper  treatment  essential,  if  permanent 
crippling  is  to  be  avoided. 

We  must  recall  certain  lines,  angles,  and  triangles  which  are  useful 
in  studying  damage  to  the  upper  end  of  this  bone.  These  lines  are 
illustrated  by  the  figures.  Nelaton's  line  especially  is  useful.  We 
determine  it  by  stretching  a  tape  from  the  anterior-superior  spine  of 
the  ilium  to  the  tuberosity  of  the  ischium.  Normally  the  top  of  the 
great  trochanter  lies  just  below  this  line  about  opposite  to  the  sym- 
physis pubis.  The  internal  condyle  of  the 
f(>mur  looks  in  the  same  general  direction  as 
The  head  and  neck  of  the  femur.  We  deter- 
mine the  relative  length  of  the  legs  by  measur- 
ing from  the  anterior-superior  spine  of  the 
ilium  to  the  tip  of  the  malleolus  of  the  tibia. 

Fracture  of  the  neck  of  the  femur  is  an  ex- 
tremely important  type  of  injury.  It  occurs 
most  often  in  elderly  persons,  though  it  may 
be  found  at  any  age.  In  the  old  it  may  occur 
without  any  obvious  traumatism — indeed  it  is 
probable  that  the  delicate  shell  of  bone  in  the 
neck  of  an  ancient  femur  may  be  broken  by 
the  mere  weight  of  the  patient's  body,  by  a 
slight  twist,  or  by  a  trifling  fall.  Fracture  of 
the  neck  of  the  femur  may  be  loose;  or  may 
be  solidly  impacted,  with  a  slight  resultant 
shortening  of  the  whole  leg.  The  fracture 
may  be  within  or  without  the  capsule,  but 
that  is  of  extremely  small  importance  as  com- 
pared with  the  question  of  impaction.  Im- 
pacted fractures  unite  rapidly.  Unimpacted 
fractures  may  never  unite. 
A  patient  the  victim  of  fracture  of  the  neck  of  the  femur  lies  upon 
the  ground  helpless  and  in  a  characteristic  attitude — the  foot  everted,  the 
leg  rolled  outward.  There  is  a  slight  fulness  in  the  upper  part  of 
Scarpa's  triangle;  there  is  always  slight  shortening,  which  may  be 
as  much  as  two  inches  after  the  lapse  of  three  or  four  da3's.  The  great 
trochanter  is  above  Xelaton's  line. 

If  the  fracture  be  loose,  one  feels  crepitus.  Never  break  up  an 
impacted  fracture  in  order  to  produce  crepitus.  In  rare  cases  of 
impaction  of  the  anterior  portion  of  the  neck,  inversion  of  the 
foot  takes  place.  Eversion  is  the  common  posi'^ion.  In  all  cases  of 
impacted  fracture  with  permanent  rotation  of  the  foot  the  surgeon 
must  assure  himself  that  a  didocation  is  not  present.  On  such  symp- 
toms and  signs  as  I  have  named  one  establi.shes  the  diagnosis  of  fractured 
neck  of  the  femur,  remembering  always  that  he  must  not  manipulate 
the  joint  and  handle  the  leg  in  a  prolonged  search  for  crepitus. 

Brvant's  well-known  method  of  measurement  is  u.seful:    With  the 


Fig.    594. — Femur;     iieac 
and  neck.   Note  structure 


SPECIAL    FHACTl'IiKS    A\D    THEIR    TFtKATMIOXT 


897 


patient  lying  on  his  buck  and  the  limbs  equally  outstretched,  mark 
upon  the  «kin  tlie  tip  of  the  trochanter,  draw  a  perpendicular  line  from 
the  anterior-supcM'ior  spine  to  the  bed  on  which  the  patient  is  lying, 
and  stretch  a  line  from  the  trochanter  to  this  perpendicular.  If  there 
is  fracture  of  the  neck  of  the  femur  this  last  line  Avill  be  shorter  on 
the  affected  side  than  on  the  sound  side. 

The  course  and  the  outlook  in  the  case  of  a  fractured  neck  of  the  femur 
vary  greatly — depending  largely  on  the  age,  the  \-igor,  and  the  general 
condition   of  the   patient.     Feeble   old   persons  with   this   injury   fre- 


Fig.  595. — Vertical  section  of  hip-joint, 
seen  from  behind.  The  angle  which  the 
head  xmder  normal  conditions  forms  with  the 
shaft  (127  degrees)  is  marked  out:  /,  Rim  of 
acetabulum  in  vertical  section;  C,  cavity  of 
joint  (exaggerated),  showing  the  extent  of 
the  joint  capsule;  L,  ligamentum  teres 
(Eisendrath).     (Scudder.) 


Fig.  596. — Measurement  of 
lower  extremity.  Patient  ly- 
ing on  the  back  looked  at  from 
above.  Position  of  tape,  hands, 
and  Hmbs  to  be  noted  (Scud- 
der). 


quently  die  from  the  shock,  or  from  the  confinement  to  bed, — being 
carried  off  in  the  latter  case  by  hypostatic  pneumonia.  Our  rule, 
therefore,  is  to  have  old  patients  sit  up  as  much  as  possible^  in  bed  or 
in  a  chair,  fixing  the  fracture  in  plaster  if  the  fragments  be  loose ;  while 
if  the  fracture  be  impacted  no  fixation  apparatus  is  required  frequently. 
The  bones  of  the  impacted  cases  always  unite,  but  in  the  case  of  loose 
fractures  permanent  non-union  even  is  not  inconsistent  with  a  useful 
leg,  especialh'  if  the  patient  be  provided  with  a  proper  ambulatory 
apparatus. 

The  treatment  of  ''fractured  hip"  deserves  some  further  con- 

57 


898 


MINOR    SURGERY — DISEASES    OF    STRUCTURE 


sideration  than  we  have  given  it  in  the  preceding  paragraphs.  We 
recognize  four  methods  of  treatment  in  use  at  the  present  time:  (a) 
The  method  of  traction  and  countertraction,  by  weight  and  pulley 
and  elevation  of  the  foot  of  the  bed,  together  with  lateral  traction  when 
such  traction  is  indicated;  (6)  the  Thomas  hip  splint,  with  or  without 
traction;  (c)  forcible  abduction  and  fixation  by  plaster  of  Paris,  with 
or  without  continuous  traction;    (d)  the  method  of  pegging. 

(a)  The  traction  method  must  be  employed  with  the  patient 
upon  a  proper  surgical  bed,  a  firm  and  narrow  mattress.  Rest  his 
knee  upon  a  pillow,  fasten  extension  strips  of  adhesive  plaster  from 
his  ankle  to  the  hip;  hang  a  five-pound  weight  over  a  pulley  upon  the 
extension  strips;  rotate  the  foot  into  a  normal  position,  and  raise  the 
foot  of  the  bed  about  6  inches  so  that  the  patient  shall  not  slide  down 


Fig.  597. — Thomas'  single  hip-splint  in 
position  (Ridlon). 


Fig.  598. — Thomas'  double  hip-splint  in 
position  (Ridlon). 


under  the  traction  of  the  pulley;  steady  the  whole  leg  with  long  heavy 
sand-bags,  and  protect  the  heel,  with  a  proper  ring  or  other  support, 
from  undue  pressure. 

(6)  The  Thomas  hip  splint  has  been  a  favorite  with  a  few  surgeons 
who  claim  for  it  excellent  results.  I  reproduce  here  the  figures  of 
Ridlon  ^  and  refer  the  reader  to  his  article,  or  to  the  admirable  descrip- 
tion given  by  Scudder  in  his  book  on  Fractures.^ 

(c)  Forcible  abduction  and  immobilization  with  or  without  traction 
is  known  as  Whitman's  method,  and  purposes  to  bring  the  bone  frag- 
ments together  and  to  hold  them  in  the  normal  position,  with  restora- 
tion  of  the  proper  angle  between  the  shaft  and  the  neck  of  the  bone. 

^  Transactions  of  American  Orthopedic  Association,  1S87. 
2  C.  L.  Scudder,  ibid,,  p.  342. 


SPECIAL    FKACTUHKS   AND   THEIR   TREATMENT 


899 


This  method  i«  applicable  especially  to  the  cases  of  young  persons  in 
whom  the  angle  is  far  more  obtuse  than  it  is  in  old  persons. 

The  patient  is  anesthetized,  while  his  pelvis  is  supported  by  a  block 
on, the  table.  The  injured  limb  is  then  abducted  through  45  degrees 
so  that  the  fragments  lie  in  a  normal  relation  to  each  other.  A  plaster- 
of-Paris  spica  bandage  is  applied  to  the  pelvis  and  thigh  (including 
the  foot  in  young  persons).  Sometimes  we  must  flex  the  thigh  in 
order  more  perfectly  to  reduce  the  fragments.  "Traction,  abduction, 
flexion,  lifting  the  trochanter  forward  (to  prevent  sagging),  rotation 
(to  correct  abnormal  eversion  or  inversion  of  the  foot),  immobilization, 
these  are  the  steps  of  the  procedure." 

We  employ  Whitman's  treatment  in  selected  cases  and  w^e  keep 
the  plaster  spica  in  place  for  about  eight  weeks.  The  weight  of  the 
body  should  not  be  allowed  to  fall 
upon  the  hip  for  many  weeks 
thereafter,  the  leg  meanwhile  be- 
ing supported  in  a  Taylor  hip 
splint,  and  the  patient  using 
crutches. 

Whitman's  method  is  logical 
and  extremely  attractive,  and  de- 
serves a  wider  application. 

(d)  The  so-called  pegging 
method^  is  a  method  of  secondary 
resort  only.  In  proper  cases  it  is 
an  extremely  valuable  procedure, 
but  its  field  of  usefulness  is  limited. 
In  general  terms  we  employ  it  in 
sound  adults  with  fracture  of  the 

neck  of  the  femur  when  apposition  of  the  fragments  is  shown  by  the 
a:-ray  to  be  so  faulty  as  not  to  permit  of  proper  union. 

In  old  ununited  fractures  of  the  hip  also  we  may  employ  the 
pegging  method.  An  ivory  peg  or,  better,  a  coin-silver  nail  is  driven 
through  the  great  trochanter  and  through  the  long  axis  of  the  neck 
of  the  bone.  In  the  case  of  an  ununited  fracture  it  is  well  to  open 
the  joint  and  to  peg  the  fragments  in  plain  view.  The  best  incision 
is  a  straight  one  on  the  outer  side  of  the  great  trochanter.  We  may 
leave  the, peg  permanently,  or  may  remove  it  at  the  end  of  a  month. 
The  best  dressing  for  a  pegged  hip  is  the  plaster-of- Paris  spica. 

The  following  rules  for  pegging  will  be  found  satisfactory:  The 
affected  leg  is  adducted;  a  four-inch  nail  is  entered  one-half  inch  from 
the  anterior  edges,  and  two  finger-breadths  from  the  top  of  the  great 
trochanter.  It  is  directed  upward  and  inward,  making  an  angle  of 
about  70  degrees  with  the  shaft  of  the  bone,  and  is  driven  into  the  loose 
head.     One  should  take  a  skiagraph  of  the  joint  after  the  pegging. 

Fracture  of  the  neck  of  the  femur  in  children  has  been  discussed 


Fig.  599. — Illustrates  the  restoration 
of  the  normal  angle  by  forcible  abduction 
(Whitman). 


^  See;.H.  Augustus  Wilson,   Treatment  of  Ununited  Fractures  of  the  Neck  of  the 
Femur  by  the  Use  of  Coin-silver  Nails,  Amer.  Jour.  Orthop.  Surg.,  January,  1908. 


900  MINOR    SURGEKY— DISEASES    OF    STRLCTURE 

recently  by  a  number  of  writers,  especially  by  Whitman.  This  fracture, 
which  is  properly  an  epiphyseal  separation,  is  especially  important 
on  account  of  its  apparent  insignificance,  and  because  frequently  it 
goes  unrecognized.  It  results  commonly  from  a  fall  on  the  foot,  and 
causes  a  slight  shortening  of  the  leg,  with  a  little  outward  rotation  and 


Fig.  600. — Fracture  of  the  thigh.     Adhesive-plaster  extension  strips:    long,  upright, 
circular,  and  obliquely  applied  strips  i^Scudder). 

a  tendency  to  limp.     The  child  recovers  with  some  lameness,  but  years 
afterward  may  develop  a  coxa  vara. 

In  dealing  with  a  child  the  surgeon  must  discinguish  (by  the  J'-ra}-) 
a  true  hip  fracture  from  hip  disease;  and  treat  the  fracture  b}'  fixation 
and  abduction  in  a  plaster  splint. 


Fig.  601. — Fracture  of  the  thigh.     Extension  strips  applied,  covered  by  bandage. 
Ham-splint  applied;  two  straps  and  pad  in  ham  iScudder). 

Fracture  of  the  shaft  of  the  femur  is  the  fracture  of  this  bone 
next  in  importance  to  fracture  of  the  neck  of  the  femur.  These  shaft 
fractures  are  generally  oblique,  and  occur  in  three  favorite  locations: 
(1)  Just  below  the  lesser  trochanter;  (2)  at  the  center  of  the  shaft,  and 
(3)  above  the  condyles.  Such  fractures  are  always  due  to  great  violence, 
the  shaft  of  the  femur  being  extremely  resistant,  so  that  extensive 


SPK('1AI>  FRACTUUES  AND  THEIR  TREATMENT         901 

damage  to  the  soft  parts  often  is  cuused  even  when  the  fracture  is  not 

compoum  .^^  find  the  patient  with  a  fractured  femoral  shaft  lying  help- 
less often  in  shock  and  pain;  the  leg  rolled  inward  or  outward,  and 
the 'thigh  deformed  by  a  marked  swelling,  while  crepitus  is  apparent. 
The  surgeon  should  measure  such  a  leg  to  determine  its  shortemng 
relative  to  the  shortening  of  the  sound  leg.  Measure  from  the  anterior- 
superior  spine  to  the  tip  of  the  internal  malleolus. 

To  the  student  familiar  with  gross  anatomy,  or  to  the  unlearned 
observer  even,  it  must  seem  incredible  that  a  fractured  feinora  shaft 
could  be  treated  by  a  graduate  in  medicine,  with  the  result  of  a  striking 
deformity  and  serious  shortening  of  the  leg;  yet  I  have  been  a  witness 
in  an  entirely  justifiable  law-suit  brought  against  a  reputable  physician 
who  treated  for  three  months  a  fractured  femur  in  a  child  of_  six  years, 
with  the  result  that  the  femur  was  allowed  to  unite  at  a  right  angle 


v\.  fin9  Fracture  of  the  thigh.  Extension  strips  apphed.  Cotton  bandage. 
HaJ^lliXsTrSfpa", Id  coaptation  splints  about  the  seat  of  fracture,  btraps 
and  buckles  (Scudder). 

and  with  marked  shortening,  while  the  child  walked  with  an  ugly  limp 
Fractures  of  the  femur  are  not  easy  to  treat.     They  call  for  constant 
inspection,   frequent  measurements,   the   reapplication  of  apparatus, 

^'^'^The%!atmmt  of  fractures  of  the  shaft  of  the  femur  is  a  subject 
more  or  less  open  to  discussion.  There  are  those  who  maintain  that 
the  best  treatment  is  by  abduction,  extension,  and  immobihzation  m 
a  plaster-of-Paris  spica  extending  from  the  toes  to  the  «F^e  of  rt^^ 
ilium  I  do  not  feel  that  this  is  a  proper  dressmg  for  a  fracture  of  the 
shaft' in  the  case  of  an  adult.  Sometimes  it  may  do  m  the  case  of  a 
restless  and  intractable  child.  Fractures  of  the  femoral  shaft  are 
extremely  difficult  of  coaptation  and  of  proper  immobihzation.  l^or 
this  reason  such  fractures  should  be  dressed  in  an  appara  us  which  wall 
permit  of  frequent  inspection  and  the  correction  of  displacements. 
The  familiar  Buck's  extension  with  coaptation  splints  on  the  thigh 
posterior  ham-splint,  and  a  long  outside  splint,  is  the  apparatus  which 


902 


-Mixoii  sii{(;i;uv — diskashs  of  stiucti  he 


meets  the  neeessities  of  the  case.  The  coaptation  si)liiils  aie  such  as 
I  have  ah'eady  described.  They  are  shown  in  the  accompam'ing 
figure.  The  ham-spHut  should  l)e  carefully  adapted  to  the  length  of 
the  leg  and  to  its  curves,  and  should  be  heavily  padded.  The  long 
outside  splhit  should  i-(>ach  from  the  axilla  to  immediately  below  the 
ankle,  while  the  internal  sj)lint  should  reach  from  the  pei'ineum  to  just 
below  the  ankle.  The  illustration  shows  the  appeai'ance  of  this  ai)par- 
atus  and  its  application. 


Fig.  603. — Fracture  of   tlie  thigli.      Completed  apparatus,  as  in  Fig.  602,  and  in 
addition  a  long  outside  T-splint,  .straps,  and  swathe.     A\  eights  applied  (Scudder). 

The  most  important  feature  of  the  dressing,  however,  is  the  extension. 
Extension  straps  are  carried  from  one  inch  below  the  seat  of  the  frac- 
ture out  to  a  pulley,  such  as  is  figured  in  the  text,  and  the  foot  of  the 
bed  is  raised  foi-  counterextension,  as  in  cases  of  fracture  of  the  neck 
of  the  femur.  "Buck's  extension''  is  a  convenient  apparatus  for  the 
treatment  of  compound  fractures,  as  well  as  for  the  treatment  of  simple 


Fig.  604. — Fracture  of  the  tliigh.  Completed  api)ar;itus  with  Ix-d  elevated. 
The  outside  si)lint  is  broad  and  witliout  the  T  foot-piece.  The  swathe  is  veiy  snugly 
applied  (Scudder). 

fractures.  The  complete  rediu-tion  of  the  fragments  is  not  always 
immediately  possible  by  its  use,  but  the  surgeon  will  observe,  during 
the  first  few  days  of  convalescence,  that  the  affected  leg  gradually 
becomes  longer  until,  under  proper  conditions  and  with  careful  employ- 
ment of  the  extension  apparatus,  the  length  of  the  two  legs  will  often 
be  found  to  vary  not  more  than  half  an  inch. 

The  surgeon  must  guard  cai-eftdly  against  malunion  of  the  fragments 


SPECIAL    FUACTrUES    AND    THEIU    TREATMEXT 


903 


through  outwiird  rolution  of  tlic  Ici;  uiul  foot.  Thi.s  outward  rotation 
is  a  detail  of  the  treatment  whicli  must  be  seeu  to  carefully.  Fre- 
c[ueutly,  at  his  morning  visit,  the  house-surgeon  will  find  the  patient's 
foot  turned  outward  and  lying  nearly  flat  upon  the  bed,  being  displayed 
to  a  right  angle  almost.  Various  methods  are  employed  for  correcting 
such  a  malposition.  I  reproduce  here  two  sketches  taken  from  Scudder. 
They  demonstrate  well  the  type  of  malposition  to  which  I  refer  and  a 
simple  maneuver  for  its  correction. 

Supracondyloid  fracture  of  the  femur  gives  rise  often  to  an  awkward 
relation  of  the  fragments,  and  frequently  to  a  serious  deformity  in 
the  leg,  for  the  reason  that  the  gastrocnemius  muscle  rolls  backward 
the  condyles  of  the  femur,  while  the  shaft  fragment  shoots  fonvard 
toward  the  patella.  This  results  in  apposition  of  the  smooth  anterior 
surface  of  the  lower  fragment,  with  the  fractured  end  of  the  upper  frag- 
ment— a  position  which  often  prohibits  absolutely  a  firm  union. 


Fig.  605. — Form  of  stirrup  Fig.  608. — Diagram  of  section  of  leg  and  splint 

to  prevent  the  foot  assuming  an       to  show  how  a  strap  carried  from  the  back  of  the 
equinus  position  (Scudder).  leg  over  the  long  side-splint  can  prevent  eversion 

of  the  foot  and  leg  (Scudder). 


I  have  had  admirable  success,  as  have  many  others,  in  coaptating 
and  immobilizing  such  fragments  by  placing  the  knee  in  the  right- 
angled  position.  One  may  dress  the  leg  in  the  old  fracture-box  arranged 
at  a  right  angle,  or,  perhaps  more  conveniently,  one  Tcnay  employ  in  these 
cases  a  firm  plaster-of -Paris  bandage.  It  is  often  well,  however,  to 
operate  for  the  reduction  of  a  supracondyloid  fracture.  If  the  leg  were 
mine,  I  should  choose  the  operation.  The  surgeon,  when  he  operates, 
must  search  thoroughly  for  all  fragments  of  bone;  he  must  remove 
them  from  the  loose  spaces  behind  the  knee;  must  do  tenotomy,  if 
necessary,  upon  the  attachments  of  the  gastrocnemius  muscle,  and 
must  wire  the  long  fragments  in  their  proper  position.  After  such  an 
operation  the  leg  may  be  held  in  an  apparatus  of  open  splints  for  a 
few  days  until  the  superficial  wound  be  healed,  after  which  the  whole 
leg,  from  toes  to  crest  of  ilium,  may  be  secured  in  a  plaster-of-Paris 
dressing. 

Fractures  of  the  Thigh  in  Children. — At  the  Massachusetts 
General  Hospital  we  have  for  many  years  dressed  these  fractures  in  a 
suspended  position.  This  dressing  is  perfectly  comfortable.  The 
child  lies  upon  a  Bradford  frame  and  has  draped  over  him  such  appar- 


904  MINOR    SURGERY — DISEASES    OV    STRUCTURE 

atus  as  is  figured  in  the  text.  The  pulley  exercises  constant  and  proper 
extension;  a  certain  amount  of  movement  of  the  body  is  permissible, 
the  child  lies  restfully,  and  the  results  of  treatment  are  satisfactory. 

The  prognosis  of  all  fractures  of  the  shaft  of  the  femur  is  somewhat 
dubious.  We  can.  as  a  rule,  promise  the  patient  a  useful  leg;  but  we 
cannot  justly  promise  him  always  a  leg  without  deformity,  or  a  leg 
free  from  a  certain  amount  of  stiffness  and  weakness.  We  should 
keep  him  under  observation,  if  he  be  an  adult,  for  six  months  at  least, 
and  for  a  year  if  possible,  seeing  to  it  constantly  that  he  does  not  bear 
his  weight  upon  the  soft  callus  in  his  impatience  to  hasten  convalescence. 


Fig.  n07. — Fracture  of  the  femur  in  a  child.  Note  Bradford  frame  on  which 
child  rests;  the  i)osition  of  the  lower  extremity.  Shoulders  and  trunk  of  child  held 
fixed  by  straps  and  swathe.  Note  coaptation  splints,  extension,  weight,  and  pulley. 
A  comfortable  position  for  child.     An  efficient  method  of  treatment  (Scudder). 

Children  also  must  be  kept  for  at  least  four  months  under  observation ; 
though  the  prognosis  as  regards  deformity  and  function  is  generally 
good  in  their  eases. 

We  pass  now  to  another  interesting  fracture,  the  treatment  of 
which  has  of  late  years  provoked  no  little  discussion. 

Fracture  of  the  Patella 

A  certain  class  of  radical  operators — not  well  advised,  I  believe— 
have  asserted  that  in  every  case  of  fracture  of  the  patella  the  surgeon, 
as  soon  as  he  sees  the  patient,  should  cut  down  upon  the  bone  and 
should  suture  it.  There  are  two  elements  in  this  argument  which  are 
dangerous  and  objectionable;  the  immediate  operation  on  a  recent 
fracture  is  followed  by  a  high  percentage  of  infections;  while  the  in- 
discriminate operating  upon  all  types  of  fracture  of  the  patella  is  need- 


SPECIAL   FRACTURES    AND   THEIR   TREATMENT  905 

less.     Certain  fractures  of  the  patella  show  very  little  separation  of 
fragments  and  heal  promptly  under  conservative  treatment. 

We  need  not  here  discuss  the  intricate  and  interesting  relations  of 
the  patella  to  the  surrounding  parts  other  than  to  remind  the  student 
that  the  patella  lies  entirely  upon  the  articulating  surface  of  the  femur; 
that  its  lower  border  reaches  as  far  as  the  head  of  the  tibia  in  some  cases, 
and  never  lies  upon  it ;  that  the  inferior  surface  of  the  patella  is  an  ar- 
ticulating surface,  and  is  formed  of  two  facets  separated  by  a  marked 
ridge,  and  that  while  the  patella  is  a  sesamoid  bone  within  the  sub- 
stance of  the  quadratus  femoris  tendon,  it  is  not  a  bone  essential  to  the 
extension  of  the  leg,  since  the  quadratus  finds  a  broad  insertion  into 
the  lower  leg  through  its  aponeurotic  expansion  entirely  independent 
of  the  patella.  Fracture  of  the  patella  involves  always  a  fracture  into 
the  knee-joint. 


Fig.  6US. — Expectant  method  of  treating  fracture  of  the  patella.     Same  as  Fig.  615, 
with  the  addition  of  two  lateral  splints,  padding,  and  straps  (Scudder). 

The  patella,  like  other  bones,  is  fractured  by  both  direct  and  indirect 
violence.  The  fracture  by  direct  violence  is  commonly  characterized 
by  a  splintering  of  the  bone  alone — sometimes  into  two  fragments, 
sometimes  into  half  a  dozen  or  more.  The  surrounding  aponeurotic 
supports,  however,  are  not  torn  in  such  cases  of  direct  violence,  so  that 
the  bone  fragments  remain  in  fair  apposition.  A  fracture  by  indirect 
violence,  on  the  contrary,  as  when  a  man  falls  from  a  height  and  lands 
on  his  feet  with  knees  bent,  is  nearly  always  associated  with  extensive 
tearing  of  the  soft  parts  in  the  neighborhood  of  the  patella.  In  this 
case  the  violence  results  in  wrenching  the  patella  in  two,  but  a  comminu- 
tion does  not  follow.  The  two  fragments  immediately  become  widely 
separated,  and  their  approximation,  without  the  surgeon's  open  inci- 
sion, is  almost  impossible.  In  both  direct  and  indirect  violence  fractures 
there  is  marked  loss  of  power  of  extending  the  leg,  but  the  loss  of  power 
is  greater  in  the  case  of  an  indirect  violence  fracture  than  in  the  case  of 


906 


MixoH  sruoKin' — diseases  of  structike 


a  direct  violence  fracture.  W'iihout  any  treiitnient  of  the  direct  violence 
fracture  the  symptoms  may  subside,  and  a  fair  use  of  the  leg  may  be 
restored,  but  it  will  ahvays  remain  weak,  with  the  kicking  or  extending 
force  far  below  normal. 

\\\  fractures  of  the  patella  are  associated  with  a  collection  of  fluid 
in  the  knee-joint,  for  the  parts  about  this  bone  are  abundantly  supplied 
with  blood,  which  pours  out  into  the  damaged  joint.  There  results  a  clot, 
bi-uising  of  the  serosa,  a  copious  serous  effusion,  and  great  swelling  of  the 
parts  about  the  knee. 

From  Avhat  I  have  stated  it  must  be  obvious  that  the  treatment  of 
a  patella  fracture  depends  largely  on  the  nature  of  the  violence  causing 
the  fracture.  In  the  case  of  a  direct  violence  injury,  with  little  separa- 
tion of  bone  fragments,  the  surgeon  may  secure  an  admirable  result, 
with  firm  union  and  a  sound  leg,  V)y  following  the  conservative  method — 

that  is,  by  supporting  the  leg  in  a 
ham-splint  for  at  least  six  weeks,  and 
by  holding  the  fragments  firmly  in 
-—  ■'"       -  ~~«-«s    apposition    by    strapping    them    with 

surgeon's  plaster.  Obvioush-,  this 
apparatus  should  not  be  applied  until 
the  primary  and  extensive  swelling 
has  subsided.  When  union  has  been 
fairly  established,  the  patient's  leg 
may  be  put  up  in  a  long  plaster-of- 
Paiis  bandage  reaching  from  the 
ankle  to  the  groin,  and  he  may  then 
be  allowed  to  go  about  upon  crutches. 
At  the  end  of  eight  or  ten  weeks  from 
the  time  of  the  injury  the  stiff 
bandage  should  be  removed,  passive 
movements  should  be  begun,  and 
active  massage  should  be  employed 
until  fair  function  has  been  restored 
to  the  leg. 
Unfortunately,  the  patella,  once  fractured,  remains  always  some- 
what weak,  so  that  it  is  a  frecjuent  experience  to  see  secondary  fractures 
of  this  weakened  bone. 

Fractures  of  the  patella  by  indirect  violence,  w^ith  wide  separation 
and  great  effusion  into  the  joint,  call  for  operative  treatment  in  case 
the  patient  is  fairly  vigorous  and  in  condition  to  withstand  the  shock 
of  an  operation  and  the  possibility  of  infection.  Numerous  statistics, 
especially  those  collected  by  the  late  Carleton  P.  Flint,  of  New  York, 
have  demonstrated  that  immediate  primary  operation,  that  is  to  say. 
operation  within  five  days  of  the  accident,  is  ahvays  inadvisable.  Im- 
mediately after  the  accident  the  parts  are  peculiarly  susceptible  to 
infection.  After  five  days,  however,  preferably  about  the  tenth  day, 
operative  treatment  of  a  fractured  patella  is  reasonably  free  from  risk. 
The   question  of  method   in  operating  upon  a  fractured  patella 


'^^5ar- 


Fig.    (iO'J. — Skctcli    showin;,'   line    of 
incision  for  ojjeration  on  patella. 


SPECIAL    FRAr'TURES    AND    THEIR    TREATMENT  907 

has  agitated  the  profession  for  a  great  many  years,  and  a  variety  of 
plans  and  procedures  are  advocated  b}'  surgeons.  Especiallj-  there 
are  the  champions  of  burj'ing  wire  in  the  fragments,  and  there  are  those 
who  advise  suturing  the  bone  with  some  absorbable  material.  It  is 
needless  in  this  place  to  elaborate  this  discussion. 

An  excellent  practice,  and  one  that  I  have  followed  with  satisfaction, 
is  as  follows:  Tuiti  back  a  long  crescentic  skin-flap  over  the  patella 
without  opening  the  joint.  Thus  one  removes  the  line  of  skin  incision 
far  from  the  field  of  operation,  and  bj'  so  much  diminishes  the  opportim- 
ity  for  infection  through  the  skin.  Having  exposed  the  aponeurosis 
over  the  patella,  clean  it  carefully,  dissect  away  the  frayed  and  torn 
edges,  expose  the  fragments  of  bone  and  the  lacerated  parts  on  either 
side  of  the  joint,  gently  irrigate  the  joint  through  a  soft-iiibber  tube, 
secure  perfect  hemostasis,  sew  up  torn  soft  parts  with  a  lamning 
stitch  of  catgut,  and  approximate  carefully  the  bone  fragments  by 
drawing  them  together  with  interrupted  catgait  stitches  which  shall 
include  the  aponeurosis  and  periosteum  only.  Close  the  skin  incision; 
insert  a  small  drainage  wick,  put  up  the  limb  in  a  firm  posterior  wire- 
splint  or  other  similar  splint,  and  support  the  freshly  united  bone 
fragments  with  strappings  of  surgeon's  plaster.  In  this  manner  we 
secure  conditions  which  result  in  prompt  bony  union.  Commonly, 
at  the  end  of  two  weeks  I  substitute  a  plaster-of-Paris  splint  for  the 
primary  dressing;  get  the  patient  about  on  dutches  for  a  couple  of 
weeks,  and  then  four  weeks  after  the  operation  begin  passive  move- 
ments and  massage  of  the  joint.  I  am  satisfied  that  the  earlier  pas- 
sive motions  and  active  treatment  of  the  joint  advocated  by  certain 
writers  are  hazardous,  and  in  the  long  iTin  unsatisfactoiy.  Some  sur- 
geons prefer  silk  or  kangaroo  tendon  to  catgtit  in  suturing  the  bone. 
I  am  quite  reach*  to  admit  the  value  of  such  suture  materials. 

A  fractured  patella  treated  on  the  lines  I  employ  should  remain 
firmly  united,  and  the  leg  should  become  nearly  as  useful  as  formerly. 
Vnfortimately.  we  cannot  promise  the  patient  a  perfect  restoration  of 
function.  It  is  rare  to  find  a  case  of  old  patella  fracture  3'ears  after- 
ward to  be  free  altogether  from  some  slight  stiffness  and  weakness  of 
the  joint.  I  am  unable  to  corroborate  Scudder's  optimistic  statement 
that  "at  the  end  of  three  months  the  knee  should  be  functionally 
perfect." 

Fractures  of  the  Leg 

The  bones  of  the  leg  are  in  some  measure  analogous  in  their  relations 
to  the  bones  of  the  forearm,  but  the  analogy  is  by  no  means  perfect. 
The  tibia  is  the  large  and  important  bone  of  the  leg;  the  fibula  is  rela- 
tively far  less  important  than  is  either  of  the  bones  of  the  forearm. 
The  tibia  alone  enters  into  the  anatomy  of  the  knee-joint,  but  both 
tibia  and  fibula  are  concerned  with  the  ankle-joint.  The  bones  of  the  leg- 
admit  of  no  rotation,  as  do  the  bones  of  the  forearm;  indeed,  one  may 
regard  the  two  bones  of  the  leg  as  mortised  together  in  a  fashion,  and 
as  forming  one  broad  and  solid  support  for  the  body.     One  recalls  the 


908 


MINOR    SURGERY — DISEASES   OF   STRUCTURE 


fact  also  that  the  front  edjio  of  the  tibia  is  subcutaneous  practically 
throughout  its  extent;    -while  the  fil)ula  is  deeply  buried  in  muscles 


Fig.  610. — Rupture  at  tubercle  of  tibia.     Operation — step  1  (author's  case). 

except  its  head,   and  the  external  malleolus,  which  is   subcutaneous 
for  a  space  of  some  three  or  four  inches  above  the  ankle. 


Fig.  Gil. — Operation  on  tubercle  of  tibia — step  2.     Note  ligamentum  patell-r  torn 
off  and  turned  into  joint  (author's  case). 

The  tibia  suffers  fracture  more  freciucntly  than   does  the  fibiUa; 
both  bones  are  often  fractured  at  the  same  time,  while  fracture  of  the 


SPECIAL    FRACTURES    AND    THEIR    TREATMENT 


909 


fibula  alone,  except  just  above  the  ankle,  is  rare.     Most  of  the  fractures 
of  one  or  both  bones  are  due  to  direct  violence. 

Injury  to  the  tubercle  of  the  tibia  is  not  very  uncommon.  It 
is  an  accident  of  vigorous  young  men,  and  is  due  to  a  starting  of  the 
upper  epiphysis  of  the  tibia,  usually  from  indirect  muscular  violence. 
This  injuiy  is  followed  by  acute  pain  at  the  point  of  damage,  with  some 
little  swelling,  tenderness,  and  a  marked  diminution  of  the  power  of 
extension.  Then  there  follows  a  more  or  less  permanent  sense  of  weak- 
ness, with  a  return  of  pain  on  exertion.  As  Osgood  says:  "The  condi- 
tion presents  no  complete  loss  of  function,  but  is  a  severe  handicap  to 
the  active  athletic  Hfe  which  this  class  of  patients  wish  to  lead." 


Fig.  (il2. — Operation  on  tubercle  of  tibia — step  3  (author's  case). 


"We  can  bring  about  a  cure  by  immobilizing  the  knee-joint  for  from 
three  to  six  weeks;  and  if  this  simple  method  fails,  we  can  secure  the 
damaged  fragment  by  pegging  or  by  sewing  it  down  to  the  periosteum. 

A  frank  fracture  of  one  only  of  the  bones  of  the  leg  is  not  always 
obvious,  for  the  sound  bone  may  act  as  a  splint,  and  so  steadj^  the 
damaged  bone  as  to  mask  the  ordinary  evidences  of  fracture.  Of 
course,  a  fracture  of  both  bones,  or  a  compound  fracture  will  readily 
be  determined.  Generally,  the  experienced  surgeon  discovers  abnormal 
mobiHty  and  crepitus  by  seizing  the  leg  firmly  above  and  below  the 
point  of  injury  and  cautiously  manipulating  the  parts.  He  can  bring 
out  distinctly  the  point  of  pain  by  appro ximaing  strongly  his  two. 
hands.  His  diagnosis  of  fracture  will  be  confirmed  by  the  a;-ray. 
It  is  needless  to  dwell  upon  the  famiHar  symptoms — pain,  swelling, 
loss  of  power — ^which  are  common  to  aU  fractures. 

In  discussing  the  subject  of  treatment  of  fractures  of  the  leg  Scudder 


910  MINOR    SrUGHRY — DISEASES    OF    STRUCTURE 

adopts  four  tlivisioius  or  groups,  which  are  U(hniriible,  for  the  sake  of 
systematic  discussion : 

1.  Fractures  with  little  or  no  swelling  or  displacement. 

2.  Fractures  "svith  considerable  swelling. 

3.  Fractures  with  a  displacement  of  fragments  difficult  to  hold 
corrected. 

4.  Open  fractures. 

Fractures  with  little  or  no  swelling  are  fractures  of  one  bone  only, 
as  a  rule.  The  surgeon  may  elevate  the  leg  for  a  few  minutes  in  order 
to  diminish  what  slight  swelling  is  present,  and  then  he  may  dress  the 
limb  in  a  plaster-of-Paris  bandage,  including  the  ankle  and  the  knee; 
or  he  may  employ  a  temporary  dressing  with  open  splints  for  the  first 
week  and  then  substitute  for  this  pi-imary  dressing  the  plaster-of-Paris 
bandage. 

Fractures  with  considerable  swelling  and  fractures  with  a  displace- 
ment of  fragments  difficult  to  hold  corrected  require  far  more  careful 
investigation  and  treatment  than  do  fractures  of  the  preceding  group. 


Fig.  613. — The  Cabot  posterior  wire  splint  padded  completely.  Note  the  foot- 
pad of  pasteboard  covered  by  cotton  cloth  pinned  to  the  foot-piece  of  the  splint  for 
greater  security  (Scudder). 

The  swelling  is  due  to  an  effusion  of  blood  and  l}-mph.  Both  bones  may 
be  involved.  The  skin  about  the  scat  of  fracture  may  be  the  site  of 
numerous  blebs  of  varying  sizes,  while  there  may  be  marketl  shortening 
of  the  leg.  It  is  obviously  unwise  to  dress  a  leg  so  damaged  in  a 
tight  immobilizing  plaster  bandage,  since  the  circulation  may  be  thus 
interfered  with,  and  gangrene  of  the  foot  may  result ;  or  swelling  may 
subside  so  rapidly  that  the  plaster  splint  will  fail  to  hold  the  parts  in 
place,  and  a  marked  deformity  gradual!}'  will  develop. 

Fcr  such  reasons  it  is  advisable  to  put  up  the  limb  in  a  temporary 
dressing  until  the  great  swelling  has  subsided.  At  the  Massachusetts 
General  Hospital  it  has  long  been  our  practice  to  support  one  of  these 
fresh  fractures  in  a  pillow  splint,  reinforced  with  firm  wooden  splints 
on  the  sides  and  beneath  the  pillow.  This  is  an  admirable  and  com- 
fortable dressing,  in  which  the  patient  should  lie  until  the  ]3rimary 
swelling  has  subsided.  We  then  employ  as  a  permanent  (h-essing  the 
so-called  posterior  wire  splint  of  A.  T.  Cabot — a  splint  which  is  well 
demonstrated  by  the  illustration  in  the  text.     Numerous  other  forms 


SPECIAL    FRACTURES    AND    THEIR    TREATMENT 


911 


of  apparatus  have  been  used,  especially  the  well-known  molded  felt 
and  plaster  splmts.  The  leg  having  been  dressed  and  firmly  secured, 
1  recommend  the  use  of  the  hammock  or  sling.  This  raises  the  leg 
from  the  bed,  and  holds  it  comfortably  supported  and  immobilized, 
while  through  its  use  the  patient  is  enabled  to  move  his  body  about 
slightly,  and  thus  to  relieve  the  strain  of  the  dorsal  position.  If  the  leg 
sling  be  not  used,  the  patient  is  not  able  to  move  at  all  without  pain  in 
the  leg. 

Under  the  best  of  circumstances  it  is  rare  to  secure  by  the  closed 
method  of  treatment  a  perfect  approximation  of  the  damaged  bones. 


Fig.  614. — Methods  of  supporting  the  foot  in  fractures  of  the  leg  when  using  a 
posterior  spUnt:  a,  Padding  beneath  tendo  AchiUis;  b,  ring  under  heel;  c,  sling  of 
adhesive  plaster  (Scudder). 

The  heel  will  drop,  the  foot  will  become  everted,  and  the  calf-muscles 
will  exert  undue  traction,  so  that  in  one  fashion  or  another  the  bone 
fragments  are  constantly  being  pulled  out  of  position.  We  employ 
various  devices  to  obviate  these  difficulties.  We  pad  the  heel,  we  roll 
in  and  secure  the  foot;  while  one  of  the  best  of  all  maneuvers  is  the 
application  of  the  short  Desault  splint,  which  exerts  a  continuous  uni- 
form traction  upon  the  foot  and  aids  materially  in  securing  a  reduction 
and  a  fixation  of  the  fragments.  The  figure  copied  from  Scudder 
shows  how  the  screw  at  the  foot  exercises  traction,  while  the  long  splints, 
with  their  plaster  straps  at  the  top,  enforce  a  permanent  counter- 
traction. 


912 


MINOR    SURGERY — DISEASES    OF    STIU  (  TrUE 


For  the  hou.se  surgeon  there  is  probably  no  one  subject  in  the  field 
of  fractures  so  common,  so  difficult,  and  so  interesting  as  this  sul)ject 
of  fractures  of  the  leg.  The  problem  is  one  recjuiring  for  its  successful 
solution  constant  patience  and  a  stud}-  of  the  invalitl's  comfort.  Again 
I  refer  the  reader  to  the  admirable  woi-ks  of  L.  A.  Stimson  and  C.  L. 
Scudder  on  this  topic. 


Fi^.  (i !.">.-  Iracturc  of  tli(_'  !(■<:.  Cabot  poaterior  wire  splint  padded  projjeily 
according  to  the  cur\es  of  tlie  normal  leg.  A'otice  that  the  heel  is  free  from  the 
splint  (Scutider). 

Open  or  compound  fractures  of  the  leg  offer  many  opportunities 
for  the  ingenuity  of  the  surgical  dresser.  In  one  of  the  early  para- 
graphs of  this  chapter  I  discussed  in  general  terms  the  compound  frac- 
tures. The  tibia  suffers  from  compound  fracture  more  commonly  than 
does  any  other  one  of  the  important  long  bones,  for  the  tibia  is  placed 
immediately  beneath  the  skin.  The  surgeon  or  the  assistant  who  first 
sees  and  dresses  a  compound  fracture  of  the  leg  is  responsible  for  the 
life  of  the  patient,  because  it  rests  with  this  attendant,  by  his  primary 


Fig.   616. — Fracture  of  the   leg.     Cabot  posterior  wire  splint,   side  and  posterior 
wooden  splints  held  \)y  straps.     Adhesive  plaster  to  foot  and  ankle  (Scudder). 

care  to  secure  asepsis,  wound  healing,  and  bone  union;  or  it  remains 
for  him  by  his  inefficiency  to  lead  the  patient  into  a  condition  which 
shall  conduce  to  infection  of  the  wound  with  a  possible  loss  of  limb  or 
life. 

In  making  the  primary  dressing  the  surgeon  should  operate  with 
the  patient  anesthetized;  he  should  wash  the  leg  with  soap  and  water, 
and  scrub  it  with  gauze  sponges  and  the  nail-brush  after  the  hair  of 


RPEC'IAI.    FRACTURES    A\D    THEIR    TREATMENT 


913 


the  whole  leg  has  licen  thoi-oughly  shaved  away.  Then  he  completes 
his  cleansing  of  the  parts  by  scrubbing  the  leg  with  liquid  chlorinated 
soda  (1 :  20)  which  removes  effectually  all  grease  and  oily  dirt. 

The  surgeon  then  turns  his  attention  to  the  damaged  soft  parts. 
He  enlarges  the  wound  sufficient!}-  to  permit  of  a  digital  explora- 
tion of  the  deeper  tissues;  he  washes  out  the  clots  and  detritus  with 
a  long-sustained  irrigation  of  hot  salt 
solution ;  he  checks  hemorrhage,  and  com- 
pletes his  cleansing  by  soaking  the  parts 
in  hydrogen  dioxid  and  washing  that 
away  finally  with  another  long  douche 
of  hot  salt  solution.  If  the  bones  are 
badly  splintered,  he  removes  the  loose 
fragments;  if  the  larger  fragments  are 
not  brought  easily  into  apposition,  he 
secures  them  with  silver  wire ;  he  then  in- 
serts a  small  drain  deep  in  the  leg,  applies 
an  ordinary  dry  aseptic  dressing  to  the 
outer  parts,  and  puts  up  the  leg  in  a 
permanent  posterior  wire  splint  such  as  I 
have  described. 

Pott's  fracture  of  the  fibula,  like 
CoUes'  fracture  of  the  radius,  is  one  of 
those  familiar  and  much-talked-of  frac- 
tures of  which  the  literature  is  enormous. 
In  Chapter  XXVI  I  have  already  de- 
scribed how  Percival  Pott  broke  his  ankle, 
studied  the  ailment,  and  then  told  about 
it.  In  spite  of  much  talking  and  writ- 
ing, however,  one  finds  that  students 
are  curiously  ignorant  of  the  exact  nature 
of  Pott's  fracture.  Pott's  fracture  is  a 
fracture  of  the  fibula,  associated  with 
an  outward  displacement  of  the  foot. 
Scudder  put  it  neatly  thus:  ''The 
lesions  ...  in  this  fracture  are  a 
rapture  of  the  internal  lateral  ligament, 
a  fracture  of  the  tip  of  the  internal  mal- 
leolus, a  separation  of  the  lower  tibio- 
fibular articulation,  an  oblique  frac- 
ture of  the  fibula  two  or  three  inches 
above  the  tip  of  the  external  malleolus,  a 
fractureof  the  outer  edge  of  the  lower  end  of  the  tibia.  .  .  .  Mechan- 
ism: As  a  foot  is  abducted,  the  strain  is  felt  at  the  internal  lateral 
ligament  and  at  the  inferior  tibiofibular  interosseous  ligament,  and  these 
give  way.  If  the  force  continues,  the  fibula  breaks.  If  the  force  still 
continues,  the  internal  malleolus  is  pushed  through  the  skin  and 
an   open    fracture    results.      If   the   internal   lateral   ligament   holds 

58 


F  i  g.  617.  —  Short  Desault 
splint  for  the  appHcation  of  trac- 
tion to  lower  leg  fractures.  Frac- 
ture at  X.  Extension  strips  u-p 
from  the  fracture  are  fastened 
at  the  top  of  the  sphnts.  Ex- 
tension strips  down  from  the 
fracture  are  fastened  to  the  foot- 
piece.  Tightening  the  screw  at 
foot-piece  makes  traction  and 
countertraction  (Scudder). 


914 


MINOR    SUHGEHY — DISKASES    OF    STKLCTLRE 


against   this  lateral  force,  the   tip  of   the   iiiteniul  nmlleolus  may  be 
pulled  off." 

One  would  suppose  that  the  s3-mptonis  of  this  complicated  injury 
would  be  obvious  enough,  yet  it  frequently  happens  that  physicians 


Fig.  618. — Packling  the  Cabot  posterior  wire  splint.     Applying  sheet  wadding.     Tlie 
shape  and  proportion  of  the  Cabot  splint  are  apparent  (Scudder). 

treat  Pott's  fracture  as  a  sprained  ankle.  The  deformity  is  fairly 
characteristic,  however,  and  the  swelling  is  great.  Compare  the  two 
feet  and  you  will  see  the  damaged  foot  dropping  somewhat  lower  than 


Fig.   619. — Pott's  fracture   of    left    ankle.     Method   of   examining  ankle.     Lateral 
mobiUty  shown.     Note  the  grasp  of  the  foot  and  the  leg  (Scudder). 

the  sound  foot  as  the  patient  lies  upon  his  back.  Seize  the  damaged 
leg  firmly  in  your  hand,  about  4  inches  above  the  ankle,  and  squeeze 
the  two  bones  of  the  leg  together.  You  will  bring  out  a  sharp  point  of 
characteristic  pain  at  the  seat  of  the  fracture  in  the  fibula.     Sometimes 


SPECIAL    FRArTlRES    AND    THEIR    TREATMENT 


91^ 


you  may  feel  the  splintered  tip  of  the  internal  malleolus.     The  a:-ray 
tells  the  story. 

Treatment  of  this  form  of  fracture  is  entitled  to  the  greatest  respect, 
for  treatment  ill  advised,  half-hearted,  or  inappropriate  may  land  the 
surgeon  in  the  court-room.  The  first  object  of  treatment  is  to  reduce 
the  fracture  of  the  fibula  by  inverting  the  foot  so  as  to  restore  its  normal 
relations,  and  to  bring  the  astragalus  back  again  against  its  opposing 
articulating  surface  at  the  end  of  the  tibia.     It  may  happen,  as  I  have 


Fig.  620. — Pott's  fracture.  Dupuy- 
tren's  splint.  Note  length  of  splint;  posi- 
tion of  straps;  arrangement  of  padding; 
space  betw^een  foot  and  splint  (Scudder). 


Fig.  C21. — Pott's  fracture.  Dupuy- 
tren's  splint.  Note  serrations  of  splint 
and  turns  of  bandage  adducting  foot 
(Scudder). 


stated  elsewhere,  that  damaged  tendons  or  the  soft  parts  will  interfere 
with  a  proper  approximation  of  the  fibula  fragments.  In  such  cases 
the  surgeon  must  transform  the  simple  fracture  into  a  compound 
fracture  at  the  point  of  fibula  fracture;  and  he  should  wire  together 
the  fragments. 

Having  reduced  the  fracture,  how  shall  we  retain  the  foot  in  place? 
Constantly  it  tends  to  fall  outward.  I  have  been  satisfied  for  years 
with  the  familiar  splint  of  Dupuytren.     This  holds  the  foot  and  leg 


916  MINOR    SUKGKKV — DISEASES    OF    STIUCTIKE 

comfortably,  and  secures  a  positive  and  constant  inversion  of  the  foot. 
The  posterior  wire  splint  of  Cabot  or  a  plaster  bandajic  may  do  well 
enough  for  mild  cases  of  Pott's  fracture,  but  they  jarely  suffice  for  the 
extreme  forms. 

Should  the  Pott's  fracture  be  originally  a  compound  fracture  with 
an  opening  into  the  ankle-joint,  the  surgeon  shoukl  tlress  the  foot  with 
the  greatest  care,  should  cleanse  thoroughly  the  jcunt.  should  wire  the 
fibula,  should  place  the  limb  upon  a  posterior  wire  splint,  and  should 
give  a  guarded  prognosis.  Rarely,  and  under  the  best  conditions, 
I  have  seen  these  injuries  lead  to  severe  and  extensive  suppuration 
necessitating  amputation  of  the  foot.  Modem  methods  of  fighting 
infections — the  employment  of  proper  opsonic  vaccines  and  constant 
antiseptic  lotions — are  rendering  these  fomiidable  compound  injuries 
less  serious  than  they  were  ten  years  ago. 

Bones  of  the  Foot 

Fractures  of  the  bones  of  the  foot,  especially  fractures  of  the  tarsus, 
frequently  can  be  determined  through  the  use  of  the  x-ray  only.  These 
fractures  are  often  due  to  falls  from  a  height,  or  to  such  a  crushing 
force  as  is  exerted  by  a  heavy  wagon-wheel  rolling  over  the  foot.  Fre- 
quently the  lesion  is  compound.  One  may  discover  crepitus,  but  the 
great  swelling  of  the  foot  may  obscure  the  grating.  Injuries  to  the 
foot,  whether  of  the  bones  or  soft  parts,  differ  markedly  from  injuries 
to  the  hand  in  this  respect — that  except  in  the  case  of  children  these 
lesions  heal  slowly.  The  circulation  in  the  foot  is  sluggish  as  compared 
with  the  circulation  of  the  hand,  so  that  a  fractured  bone  or  an  ex- 
tensive cut  of  the  foot  frequently  will  require  two  or  three  times  as 
long  for  its  healing  as  a  similar  lesion  in  the  hand.  For  such  reasons 
damaged  feet  must  be  watched  and  treated  for  a  long  time,  and,  so  far 
as  possible,  the  patient  must  be  ad^-ised  and  encouraged  to  keep  his 
bed,  frequently  for  weeks,  rather  than  to  get  up  and  move  about  on 
crutches  as  his  inclination  prompts  him. 

One  of  the  tarsal  bones  commonly  fractured  is  the  astragalus.  Its 
fracture  is  often  mistaken  for  a  simple  sprained  ankle.  Discover  it 
with  the  x-ray.  Dress  it  in  a  plaster-of-Paris  bandage,  running  from 
the  toes  to  the  knee.  Remove  the  plaster  at  the  end  of  two  weeks. 
Employ  proper  massage  for  a  month,  when  a  satisfactory  residt  will 
be  secured,  though  the  foot  may  not  be  perfectly  comfortable  until 
four  or  even  six  months  have  elapsed. 

The  OS  calcis,  or  heel  bone,  is  often  fractured,  especially  by  a  fall. 
Sometimes  the  fragments  are  greatly  separated  through  being  pulled 
apart  by  the  gastrocnemius  muscle.  The  x-i'ay  will  show  the  extent 
of  the  damage.  In  order  to  reduce  the  fragments  it  may  be  necessary 
to  perform  tenotomy  of  the  tendon  of  Achilles,  or  to  remove  even  some 
of  the  bone  splinters.  When  the  fragments  have  been  brought  well 
together,  the  injured  foot  should  be  dressed  in  a  plaster-of-Paris  bandage. 

Both  the  astragalus  and  the  os  calcis  may  be  the  subject  of  com- 


SPECIAL    FRACTURES    AND    THEIR    TP.EATMENT  917 

pound  fracture,  in  which  case  the  damuK(Hl  bones  should  be  carefully 
cleansed  and  treated  on  the  lines  already  laitl  down  in  our  discussion  of 
compound  fractures. 

The  other  smaller  bones  of  the  tarsus  occasionally  are  crushed  by 
direct  violence.  One  ascertains  the  exact  nature  of  their  fracture 
through  .r-ray  investigation.  Treatment  is  by  rest  and  an  ice-bag  until 
the  swelling  has  subsided,  after  which  the  whole  foot  should  be  put 
up  in  a  plaster  bandage. 

Fracture  of  the  metatarsal  bones  is  freciuent,  and  is  due  nearly  al- 
wavs  to  direct  violence.  The  first  and  fifth  metatarsals  are  the  bones 
coEQmonly  broken,  and  the  symptoms  are  swelling,  crepitus,  pain, 
abnormal  mobility,  and  inability  to  stand  on  the  foot.  There  is  never 
great  displacement,  but  an  approximation  of  the  fragments  is  neces- 
sary in  order  that  the  patient  may  be  able  to  walk  freely  and_  easily 
after  union  has  taken  place.  In  the  case  of  great  displacement  it  may 
be  necessary  to  employ  temporary  traction  by  special  wooden  sphnts, 
but  ordinarily  a  plaster  splint  embracing  the  whole  foot  will  suffice. 
These  plaster' splints  for  fractures  of  the  bones  of  the  foot  should  always 
extend  from  the  tips  of  the  toes  to  above  the  swell  of  the  calf. 

Fracture  cf  the  phalanges  of  the  foot  is  a  rather  rare  accident. 
I  have  known  cases  in  which  the  patient  fractured  a  phalanx  of  the 
toe  by  stubbing  the  toe  while  walking  barefoot.  The  displacement  in 
these  cases  is  slight  and  union  is  fairly  prompt.  Generally,  a  simple 
wooden  plantar  splint,  properly  padded  and  held  in  place  with  adhesive 
straps,  is  sufficient.  The  plantar  splint  which  covers  the  entn-e  sole 
of  the  "foot  is  the  most  comfortable.  Sometimes  it  is  well  to  immobilize 
the  ankle-joint  also  in  plaster.  The  patient  should  usually  be  kept 
quiet  with  the  foot  elevated  until  fair  union  has  taken  place. 

Bones  of  the  Face 

Fractures  of  the  bones  of  the  face  are  interesting  and  extremely 
important,  because  upon  the  integrity  of  the  facial  bones  depends 
the  expression  of  the  countenance  and  the  familiar  alinement  of  the 
features.  The  bones  of  the  face  are  not  long  bones;  their  structure  is 
irregular,  while  their  outlines  are  various;  moreover,  they  are  mostly 
so  placed  as  to  permit  of  no  proper  splinting  or  immobilization,  so 
that  often  it  is  necessary  for  the  surgeon  to  contrive  and  adopt  special 
maneuvers  for  the  treatment  of  special  fractures. 

The  nasal  bones  are  subject  to  fracture,  while  their  damage  may 
cause  a  marked  deformity.  Moreover,  they  are  functionally  con- 
cerned with  breathing,  so  that  their  displacement  may  seriously  inter- 
fere with  the  comfort  of  life. 

The  nasal  bones  are  usually  fractured  near  their  lower  edge,_  and  the 
fracture  is  compound,  either  Wo  the  nose  or  through  the  skin,  while 
at  the  same  time  the  cartilage  of  the  septum  is  generally  damaged. 
The  upper  lateral  cartilages  also  may  be  torn  from  their  attachments 
to  the  nasal  bones,  when  there  results  a  deformity  which  simulates 
fracture  of  those  bones. 


918 


MINOlt    SIRGEHY — DISEASES    OF    STRrCTlHE 


Fracture  of  the  nose  is  not  painful  after  the  initial  injury,  but  there 
is  nearly  always  marked  swelling  and  crepitus  with  the  defonnity. 

Before  undertaking  the  ti^eaiment  of  a  nasal  injury  the  sui'geon 
should  examine  carefully,  with  the  aid  of  a  head-mirror,  the  interior 
of  the  nostrils,  and  should  correct  any  obvious  displacement  of  the 
septum.  Cocain  anesthesia  or  general  anesthesia  may  be  necessary 
to  accomplish  this  result,  for  the  manipulation  is  painful.  Then  the 
surgeon  should  replace  the  fractured  bone  if  there  be  a  fracture,  using 
within  the  nose  a  proper  elevator.  Roe's  elevator  is  a  useful  instru- 
ment. The  surgeon  must  then  endeavor  to  hold  the  replaced  bones 
in  position.  He  may  do  this  fairly  well  by  packing  the  nostrils  with 
gauze,  if  the  fracture  be  high ;  while  if  there  is  a  low  deviation,  he  may 
well  use  the  Asch  tube.     In  the  case  of  a  crushed  nose  he  may  model 

or  reconstruct  the  nose  over  the 
Asch  tube,  one  tube  being  placed  in 


Fig.  622. — Fracture  of  nasal  bones. 
Elevation  of  depres.sed  bone  by  instru- 
ment introduced  into  the  nostril  (Scud- 
der). 


Fig.  62.3. — Cobb's  splint  applied  to 
a  case  of  fracture  of  the  nose.  Tlie 
head-band  is  .so  adaj)ted  to  the  shape  of 
the  liead  that  it  remains  fixed  and  of- 
fers a  point  of  counterpressure  (Scud- 
der) 


each  nostril  to  preserve  its  contour  and  lumen.  In  those  rather  fre- 
quent cases  which  do  not  show  deformity  one  need  use  no  splint.  Always 
when  the  mucous  membrane  of  the  nose  is  damaged,  with  a  coincident 
compound  fracture,  the  nares  must  be  kept  scrupulously  clean  with 
gentle  douching,  for  which  there  is  nothing  better  than  a  50  per  cent, 
alkalol  wa.sh,  or  Seller's  solution. 

Various  external  splints  have  been  devised.  I  reproduce  Cobb's 
splint  and  Coolidge's  splmt,  either  of  which  is  effective,  though  the 
Coolidge  splint  is  much  the  cheaper. 

Make  no  promise  as  to  the  resulting  deformity,  for  until  the  initial 
swelling  has  subsided  and  union  is  complete,  no  man  may  say  whether 
a  deformity  will  be  permanent  or  not.     In  case  of  a  slight  depression 


SPECIAL    FRACTURES    AND    THEIR   TREATMENT 


919 


or  deviation  following  healing,  the  .surgeon  may  remedy  the  defect 
bv  the  judicious  subcutaneous  injection  of  paraffin. 

'  Fracture  of  the  malar  bone  generally  results  m  a  deformity 
of  the  face  in  a  depression,  which  may  or  may  not  be  noticeable 
to  the  patient's  friends,  though  the  man  himself  is  sure  to  com- 
plain of  the  slightest  imperfection.  Indeed,  it  is  not  easy  always  to 
make  out  a  fracture  of  the  malar  bone.  The  best  method  of  examina- 
tion is  to  stand  behind  the  patient,  and  with  the  finger  and  thumb 
of  either  hand  to  seize  both  malars,  when  a  deviation  of  the  affected 
side  will  generally  be  apparent.     Fracture  of  the  body  of  the  bone 


Fi-   624.-Coolidge's  nasal  spUnt:   a,  Forehead  plate;    b,  pad;    c,  screw  controlUng 
position  of  pad;  d,  head-strap  (Scudder). 

is  not  common,  but  fracture  of  one  of  its  processes  is  seen  not  infre- 
quently. Often  the  bone  appears  depressed  as  a  whole,  or  sometimes 
tilted  inward  toward  the  zygomatic  fossa.  The  deformity  is  a  depres- 
sion outside  of  and  beneath  the  eye.  There  is  often  a  stiffness,  or  even 
immobility  of  the  lower  jaw  dependent  either  upon  hemorrhage  into 
the  soft  parts  or  upon  bone  pressure.  At  the  same  time  the  coronoid 
process  of  the  mandible  may  be  fractured  and  a  subconjunctival  hemor- 
rhage may  appear  in  the  orbit  of  the  affected  side. 

We  treat  fracture  of  the  malar  bone  variously-either  by  manipu- 
lations or  by  seizing  through  the  skin  with  bullet  forceps  {h.  A 
■Codman)  and  elevating  the  fragments  of  bone,  always  with  the  patient 


920  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

anesthetized.  Sometimes  the  depressed  fragment  may  be  elevated  with 
a  bkmt  instrument  introduced  under  the  mahir  bone  from  inside  the 
cheek  without  opening  the  mucosa;  or  we  may  succeed  by  making  a 
small  incision  in  the  mucous  membrane,  and  thus  approaching  the  seat 
of  damage;  or  by  opening  the  antrum  in  the  canine  fossa  and  intro- 
ducing an  elevator  which  shall  press  up  the  fractured  bone  from  within. 

Never  undertake  an  exteinal  incision  if  it  can  be  avoided,  for  an 
external  incision  may  prove  of  little  value  for  the  elevation  of  the  bone, 
while  it  will  be  certain  to  leave  a  noticeable  scar. 

Fracture  of  the  upper  jaw  is  rather  more  common  than  fracture 
of  the  malar,  for  the  upper  jaw  is  a  more  delicately  constructed  bone 
than  is  the  malar.     A  jaw  fracture  is  usually  caused  by  a  direct  blow 


Fig.  625. — Four-tailed  bandage  for  fracture  of  tlie  lower  jaw. 

upon  the  cheek  bone,  resulting  in  the  crushing  in  of  the  external  wall 
of  the  antrum  of  Highmore.  Lothrop  ^  has  recently  published  an 
interesting  and  valuable  essa}^  on  this  subject.  After  discussing  the 
nature  and  anatomy  of  upper  jaw  fractures,  he  describes  three  methods 
of  operative  treatment,  pointing  out  truly  that  operative  treatment 
is  the  only  satisfactory  mode  of  treatment:  First,  operation  by  incision 
over  the  malar — a  method  to  be  discarded;  second,  the  introduction 
of  blunt  instruments  pushed  up  through  the  mouth — less  objectionable 
than  the  first  method,  but  generally  ineffective  and  inadvisable.  Third, 
Lothrop's  own  method,  which  I  believe,  from  my  personal  experience, 
to  be  far  the  most  valuable.     This  method  consists  in  elevating  the 

^  Howard  A.   Lothrop,  Fractures  of  the  Superior  Maxilla:    A  Method  for  the 
Treatment  of  Such  Fractures,  Boston  Med.  and  Surg.  Jour.,  January  4,  1906. 


SPECIAL  FRACTURES  AND  THEIR  TREATMENT 


921 


malar,  together  with  the  various  fragments  of  the  maxilla,  working 
through  a  sn.iall  opening  into  the  antrum  through  the  canine  fossa. 
The  operator  makes  a  short  horizontal  incision  along  the  junction  of 


Fig.  626. — Hard-rubber  splint,  with  arms  and  posterior  strap  (Scudder). 

the  mucous  membrane  of  the  alveolus  and  cheek;  he  feels  the  line  of 
fracture  often,  after  having  cut  clown  upon  the  bone.  He  then  pushes 
a  director  through  the  opening  into  the  antrum — an  easy  procedure. 


Fig.  627. 


-Hard-rubber  splint,  with  arms  and 
(Moriarty ) . 


applied.     Similar  to  Fig.  626 


He  enlarges  this  opening  sufficiently  to  pass  into  the  antrum  a  steel 
sound  (No.  24  French).  With  this  instrument,  and  by  a  little  forceful 
manipulation,  the  operator  may  press  the  fragments  of  bone  up  into  their 
position  and  can  hold  them  there  by  packing  firmly  the  antrum  with 


922  MINOR   SURGERY— DISEASES    OF   STRUCTURE 

gauze.  The  guuze  should  be  left  in  place  for  four  or  five  days,  when  it 
is  withdrawn,  the  bone  cavity  carefully  syringed  out,  and  with  proper 
aseptic  precautions  allowed  to  heal.  1  have  seldom  been  obliged  to 
keep  these  patients  more  than  a  week  in  the  hospital. 

Fractures  of  the  lower  jaw  can  nearly  always  be  determined  by 
palpation,  for  the  lower  jaw  is  superficial,  with  the  exception  of  a  small 
portion  of  the  ramus.  Fractures  of  the  ramus  are  rather  rare,  and 
fractures  of  the  condyloid  and  coronoid  processes  are  extremely  rare. 
One  sees  that  most  fractures  of  the  lower  jaw  must  necessarily  tear 
the  mucous  membrane  of  the  mouth  and  must  therefore  be  classed  as 
compound  fractures.  The  result  is  that  these  fractures  are  more 
serious,  more  dangerous,  and  more  difficult  of  treatment  than  would  at 


Fig.  628. — Lateral  view  of  the  Matas  splint  in  situ,  as  shown  on  aduh  skull  (Scudder). 

first  appear.  The  secretions  of  the  mouth  enter  into  the  wound;  sepsis 
results,  with  consec^uent  necrosis  and  possible  abscess  formation,  so 
that  in  the  treatment  of  these  injuries  the  surgeon  must  employ  constant 
and  scrupulous  cleansing — mouth-washes,  douches,  and  aseptic  irriga- 
tions. 

The  treatment  of  fracture  of  the  jaw :  Anesthetize — for  the  procedures 
are  painful,  not  only  the  cleansing  for  the  prevention  of  serious  infec- 
tion, but,  what  is  of  almost  equal  importance,  the  manipulations  for  the 
preservation  of  the  alinement  of  the  teeth.  We  attain  this  proper 
alinement  by  a  complete  reduction  of  the  bone  fragments,  if  necessary-, 
by  removing  loose  and  obstructing  teeth  which  may  interfere  with  such 
reduction. 


SPECIAL    FRACTURES    AND   THEIR   TREATMENT 


923 


As  for  the  common  fnu-ture,  that  of  the  body  of  the  bone,  the  frag- 
ments may  as  well  be  retained  primarily  by  the  old-fashioned  four- 
tailed  bandage  until  a  permanent  splint  has  been  manufactured  and 
applied.  There  are  many  varieties  of  permanent  splints,  and  most  of 
them,  being  made  from  molds  of  the  jaw,  fall  naturally  to  the  province 
of  the  dentist.  Indeed,  it  is  a  common  practice  among  surgeons  in 
municipal  hospitals  to  transfer  to  the  hospital's  dental  department  sim- 
ple cases  of  fractured  jaw.  I  reproduce  here  illustrations  of  certain 
dental  splints  which  are  in  ordinary  use.  At  one  time  it  was  common 
practice  to  attempt  immobilization  of  the  fragments  by  wiring  to- 
gether the  two  teeth  on  either  side  of  the  fracture.     This  practice  is 


Fig.  629. — Compound  fracture  of  lower  jaw,  caused  by  fist  blow.  Line  of 
fracture  oblique,  bisecting  lower  jaw  at  angle  and  terminating  above  beliind  last 
molar  tooth.  Great  displacement  and  mobility  of  fragments.  Reduction  and 
apposition  only  obtained  by  splint.  Barton  bandage  used  to  immobilize  jaws  with 
the  spUnt.     Splint  worn  eighteen  days  and  followed  by  excellent  results  (Matas). 

ineffective,  since  such  wiring  loosens  or  pulls  out  of  place  the  teeth  so 
treated.  There  is  a  satisfactory  method  of  wiring,  more  or  less  in 
vogue,  however.  This  consists  merely  of  fastening  together,  as  it 
were,  in  a  wire  splint  a  large  number  of  teeth  on  either  side  of  the  frac- 
ture, weaving  a  pliable  silver  wire  in  and  out  among  them.  For  prac- 
tical purposes  I  have  found  this  method  serviceable.  It  is  cleanly,  it 
allows  of  ready  access  to  the  damaged  parts,  and  it  is  not  especially 
disagreeable  to  the  patient,  since  it  does  awa}'  with  the  cumbersome 
splints  and  harness  which  are  frequently  employed  in  hospital  practice. 
Fractures  of  the  ramus  of  the  lower  jaw  are  much  more  difficult  to 
hold  in  place  than  are  fractures  of  the  body  of  the  jaw.     These  frac- 


924  MINOR   SURGERY — DISEASP^S   OF   STRUCTURE 

tures  of  the  ramus  may  be  fairly  well  immobilized  by  a  carefully  applied 
four-tailed  bandage,  or,  better  still,  is  the  molded  leather  splint  of  Mori- 
arty,  or  the  ingenious  but  somewhat  cumbersome  splint  of  Matas. 

We  have  now  considered  the  common  and  important  fractures  of  the 
bones  throughout  the  body.  It  is  not  possible  in  this  writing  to  deal 
adequately  with  the  numerous  and  distressing  complications  of  frac- 
tures. One  remembers  also  that  many  serious  wounds  of  the  soft 
parts  are  associated  with  fractures,  and  that  the  treatment  of  such 
fractures  is  a  subordinate  part  of  the  care  of  the  patient.  Theie  are, 
further,  certain  special  types  of  fractures  due  to  special  forms  of 
injury,  man}^  of  the  most  important  of  which  are  gun-shot  fractures. 
Gunshot  fractures  are  necessarily  compound  fractures,  and  the  accident 
or  damage  to  the  bone  is  in  proportion  to  the  velocity  of  the  projectile 
and  the  character  of  the  bullet.  The  old-fashioned  leaden  bullet,  of 
low  velocity,  gives  often  an  ugly  wound  with  an  extensive  splintering 
of  the  bone;  while  the  modern  high  velocity  conic  bullet  may  do  little 
more  than  pierce  the  bone  and  cause  a  slight  splintering.  X-va.y  plates 
are  needed  in  order  to  determine  the  exact  nature  of  these  various 
fractures;  and  the  treatment  of  such  fractures  must  be  decided  on 
general  surgical  principles.  In  broad  terms,  one  may  sa}'  that  a  bone 
extensively  splintered  must  be  cut  down  upon  and  trimmed,  while  a 
bone  merely  pierced  will  probably  heal  without  any  great  disturbance. 
It  is  rarely  necessary  to  search  for  a  bullet  embedded  in  the  tissues, 
unless  the  bullet  is  obvioush'  a  source  of  present  irritation.  A  bullet, 
like  any  other  foreign  body,  may  remain  indefinitely  in  a  patient 
without  creating  noticeable  damage. 

Pathologic  Fractures 

Pathologic  fractures,  by  which  we  mean  .fractures  resulting  from 
new-growths,  from  infections,  and  from  bones  rendered  brittle  by  dis- 
ease, occasionally  are  seen.  Such  fractures  call  for  no  special  discus- 
sion in  this  place.  It  is  obvious  that  fractures  due  to  malignant  disease 
are  subordinate  to  the  primary  disease  which  must  be  the  object  of  the 
surgeon's  care;  while  fractures  due  to  such  non-malignant  processes 
as  rickets,  etc.,  must  be  treated  on  ordinary  principles,  and  the  surgeon 
must  make  every  endeavor  to  rectify  the  underlying  ailment  which  led 
to  the  fracture. 

Dislocations 

Stimson  gives  the  following  excellent  and  comprehensive  defini- 
tion of  a  dislocation:  ''A  dislocation  is  a  permanent,  abnormal,  total 
or  partial  displacement  from  each  other  of  the  articular  portions  of 
the  bones  entering  into  the  formation  of  a  joint."  A  dislocation  may 
be  partial  or  complete.  When  it  is  partial  or  incomplete,  it  is  frequently 
called  a  subluxation. 

Writers  tell  of  predisposing  and  immediate  causes  of  dislocations. 
These  refinements  need  not  concern  us  especially,  for  the  fact  is  that 


DISLOCATIONS 


925 


the  ordinan^  dislocations  which  are  presented  to  the  surgeon  for  treat- 
ment are  dislocations  of  normal  joints  which  have  been  torn  asunder 
by  extreme  and  external  violence.  Rarely  the  patient's  own  muscular 
action  may  cause  a  dislocation,  as,  for  example,  a  dislocation  of  the 
lower  jaw  through  excessive  yawning;  or  the  habitual  and  recurring 
dislocation  of  the  shoulder-joint,  produced  by  muscles  acting  upon  a 
joint  constructed  with  extremely  relaxed  ligaments. 

A  dislocation  long  unrecognized  and  unreduced  results  m  firm 
adhesions  about  the  parts,  rendering  their  subsequent  reduction  impos- 
sible without  an  open  operation.  These  old  dislocations,  like  old 
unrecognized  fractures,  are  frequent  subjects  for  law-suits.  Perhaps 
the  most  common  of  the  old  unreduced  dislocations  is  that  of  the 
shoulder-joint.  One  would  suppose  that  a  dislocation  of  the  shoulder- 
joint  should  be  easy  of  recognition.  On  the  contraiy,  in  obese  persons 
with  heavy  shoulders  and  flabby  muscles,  especially  if  they  be  short, 
stout  women,  the  deformity  of  a  dislocation  of  the  shoulder-jomt  is  by 
no  means  obvious;  the  palpation  of  the  region  is  difficult,  and  without 
an  a--ray  or  bimanual  manipulation  the  correct  diagnosis  frequently 

is  not  made.  .  7        •  i   / 

That  we  may  distinguish  clinically  between  dislocations  and  Jrac- 
tures  we  must  recognize  certain  striking  points  of  difference.  While 
there  is  pain  in  both  conditions,  the  deformity  of  a  dislocation  is  more 
marked  than  is  the  deformity  of  a  fracture,  and  the  loss  of  power  after 
a  dislocation  is  less  considerable  than  after  a  fracture;  but  the  most 
striking  distinction  is  this— a  fracture  results  in  abnormal  mobility, 
while  a  dislocation  results  in  diminished  mobility,  or  m  a  fixing  of  the 
bones  in  their  new  position. 

The  course  and  outlook  of  a  dislocation  are  shorter  and  more  favor- 
able than  is  the  case  with  a  fracture.  We  can  compare  best  the  con- 
trasted features  of  the  two  injuries  by  considenng  special  regions;  for 
example,  a  dislocation  of  the  elbow-joint  should  incapacitate  the  patient 
for  not  more  than  two  or  three  weeks,  and  the  use  of  the  joint  should 
be  completely  recovered;  while  o.  fracture  into  the  elbow-jomt  means 
many  months  of  treatment,  often  resulting  in  a  permanent  impairment 
of  function.  Again,  the  dislocation  of  one  of  the  phalanges  imphes  a 
disablement  of  not  more  than  a  week  or  two,  with  perfect  restoration 
of  motion;  while  a  fracture  of  one  of  the  phalanges  is  followed  by 
disablement  for  from  four  to  six  weeks,  with  occasionally  permanent 
limitation  of  motion  and  power. 

The  treatment  of  dislocations  is  interesting  and,  m  general  terms, 
is  active.  The  sooner  a  dislocation  is  discovered,  the  more  easily  may 
it  be  reduced.  The  original  force  causing  the  injury  and  the  force  neces- 
sarily apphed  to  correct  it  imply  a  great  deal  of  traumatism  to  the  joint, 
as  well  as  a  certain  amount  of  tearing  of  the  capsule.  Often  this  trau- 
matism results  in  irritation  of  the  joint  serosa,  m  an  outpouring  of  a 
considerable  exudate,  in  effusion  into  the  surrounding  tissues  even,  and 
not  infrequently  in  a  straining,  stretching,  and  tearing  of  the  hgaments. 
For  such  reasons  the  surgeon  must  enjoin  absolute  rest  for  the  joint 


926  .MINOR   SURGERY — DISEASES    OF   STRUCTURE 

for  a  day  or  two  after  the  dislocation  has  been  reduced.  It  is  not  neces- 
sary to  put  up  the  limb  in  an  ininiobilizing  dressing  of  plaster  of  Paris, 
but  it  is  necessary  to  hold  it  snugly  and  comfortably  in  place  with 
heavily  padded  bandages.  During  these  first  few  days  the  effusion 
subsides ;  the  injection  and  hyperemia  of  the  parts  diminish ;  the  swelling 
disappears,  and  the  region  becomes  noi'mal  in  appearance. 

In  order  to  facilitate  these  natural  processes  we  then  prescribe 
massage  for  the  joint  and  surrounding  parts,  and  as  the  subsequent 
healing  progresses,  we  stimulate  and  hasten  it  by  continued  massage. 
Old  practitioners  will  recognize  this  treatment  as  quite  different  from 
the  long-continued  immobilization  of  former  times.  The  present-day 
active  measures  return  the  joint  to  a  normal  and  useful  function  with 
surprising  rapidity;  instead  of  waiting  for  many  months,  as  used  to  be 
the  case,  we  now  expect  a  return  of  usefulness  in  a  joint  in  a  far  shorter 
time. 

SPECIAL   DISLOCATIONS 

Special  dislocations  offer  special  considerations  to  the  student,  and 
some  of  these  considerations  we  have  already  taken  up.  In  Chapter 
XXV,  I  have  discussed  briefly  the  question  of  dislocations  of  the  vertebrse, 


Outer  end  of 
clavicle 


Fig.  B.'^O. — Acromioclavicular  dislocation.  Dislocation  of  the  outer  end  of  left 
clavicle  upward.  Complete  form.  Disability  of  upper  arm,  certain  movement.s 
painful.  Treatment  of  tliis  dislocation  is  often  successful  by  pressure  applied  after 
reduction,  as  shown  under  Fracture  of  Clavicle.  Open  incision  and  suture  are  indi- 
cated if  reduction  is  impossible  and  disability  exists  (Scudder). 

especially  of  the  cervical  vertebrae;  and  I  have  already  in  this  present 
chapter  referred  to  dislocations  of  the  ribs,  especially  of  the  ribs  upon 
the  costal  cartilages.  These  dislocations  of  the  ribs  are  essentially 
similar  to  fractures  of  the  ribs  in  their  general  effect  upon  the  patient, 
and  their  treatment  is  similar  to  the  treatment  of  fractured  ribs. 

Dislocations  of  the  Clavicle. — The  clavicle  may  be  dislocated 
at  either  its  proximal  or  its  distal  end,  and  these  dislocations  may  be 
found  extremely  difficult  of  reduction  and  fixation.  In  general  terms, 
when  the  dislocation  is  at  the  yroximal  end  of  the  clavicle,  we  perceive 


SPECIAL   DISLOCATIONS 


927 


that  reduction  is  brought  about  by  manipulations  of  the  shoulder:  by 
drawing  the  shoulder  outward  and  backward,  and  by  manipulating  the 
dislocated  bone,  we  can  usually  bring  it  back  into  place.  The  difficult 
task  of  retaining  it  in  place  will  put  the  surgeon  to  his  trumps.  The 
shoulder  must  be  bandaged  and  strapped  into  such  a  position  as  to  favor 
present  retention  of  the  bone,  and,  if  necessary,  the  patient  must  be 
kept  quiet  in  bed  for  weeks  even.  So  difficult  and  so  disheartening  are 
these  cases  often,  however,  and  so  persistently  does  the  dislocation 
recur,  that  the  surgeon  frequently  finds  himself  on  the  horns  of  a  dilemma ; 
either  he  must  submit  to  the  forces  of  nature  and  allow  the  dislocation 
to  remain  unreduced,  or  he  must  transform  the  simple  dislocation  into 
an  open  one  and  retain  the  bone  in 
place  by  suturing.  I  have  found  this 
last  measure  to  be  satisfactory. 

Dislocations  of  the  clavicle  at  its 
distal  end  are  extremely  difficult  of 
treatment  also.  It  is  a  simple  matter 
to  reduce  them,  but  their  retention 
again  is  a  problem.  We  reduce  them 
by  manipulating  the  shoulder.  We 
retain  them  theoretically  by  such 
strapping  as  I  have  illustrated  in  the 
sketch.  As  a  matter  of  practice,  how- 
ever, we  find  that  the  most  efficient 
method  of  holding  these  dislocations 
in  place  is  by  wiring,  provided  the 
patient  is  not  willing  to  submit  to  the 
slight  deformity  of  a  permanent  dis- 
location and  the  trivial  loss  of  func- 
tion which  this  entails. 

Dislocation  of  the  shoulder  is 
one  of  the  commonest  of  dislocations. 
The  head  of  the  humerus  nearly  always 
leaves  the  joint  through  the  lower 
portion  of  the  capsule,  and  goes  to 
rest  either  beneath  the  glenoid  cavity 
(subglenoid  dislocation)  or  beneath 
the  coracoid  process  (subcoracoid  dis- 
location). There  is  also  a  subspinous  or  backward  dislocation— a 
condition  of  the  greatest  rarity.  For  the  purposes  of  treatment  it 
matters  Httle  whether  the  dislocation  be  subglenoid  or  subcoracoid. 
Either  one  of  the  forward  dislocations  gives  rise  to  a  characteristic 
and  definite  picture  and  chain  of  symptoms:  The  patient  sits  bent 
forward  and  supports  in  his  hand  the  elbow  of  his  injured  arm;  the 
normal  outline  of  his  shoulder  is  changed;  the  deltoid  is  flat  instead  of 
rounded ;  the  elbow  protrudes  from  the  side  and  is  fixed  in  that  position ; 
the  head  of  the  bone  may  be  palpated  bimanually  in  the  axilla.  The 
surgeon  should  confirm  these  observations  by  the  x-ray,  through  which 


Fie.  631.- 


-Dressing  for  dislocated 
clavicle. 


928 


MINOR    SURGERY — DISEASES    OF    STRLCTUUE 


means  also  he  must  determine  upon  the  i)rcscn('e  or  ub.sence  of  a  coinci- 
<lcnt  fracture. 

The  treatment  of  dislocation  of  the  shouldei'  is  exti'cincly  easy  in  case 
the  dislocation  be  recent.     The  head  of  the  bone  \\\U  slip  back  into  its 

1 


Fig.  632. — View  of  the  acromiocla\icular  joint  from  al)o\o.     To  illustrate  a  suture 
passed  through  transverse  drill  holes  in  the  acromion  A  and  clavicle  B  (Scudder). 

socket  almost  at  the  touch  often,  if  the  patient  be  etherized;  and  he 
should  generally  be  etherized  for  the  examination  and  reaction. 


/if".  J^' 


ot 


Fig.  633.— Dislocated  left  shoulder. 


The  old  method  of  reducing  a  shoulder  dislocation  is  to  make  trac- 
tion upon  the  humerus  by  grasping  it  at  the  ell)ow  while  the  arm  is 


RPECIAL    DISLOCATIONS 


929 


extended  at  a  right  angle  to  the  body.  An  assistant  holds  the  patient 
firmly  upon  the  table,  if  necessary,  with  a  folded  sheet  strapped  about 
the  chest.  While  the  surgeon  makes  traction  upon  the  arm  with  one 
hand,  he  brings  the  elbow  gradually  to  the  side  and  manipulates  the 
head  of  the  bone  back  into  its  socket  with  the  other  hand,  or  he  may 
have  these  shoulder  manipulations  done  by  an  assistant.     An  excellent 


Fig.  634. — Reducton  of  subcoracoid  dislocation  of  the  shoulder.  First  position 
{see  Fig.  635) ;  elbow  at  side,  forearm  rotated  outward.  Note  fulness  (head  of  humerus) 
beneath  coracoid  process  (to);  absence  of  head  of  humerus  under  acromion  (Z);  re- 
laxed muscles  {g,  h,  j);  a,  deltoid;  b,  pectoralis  major;  c,  pectoralis  minor;  d, 
coracobrachialis;  e,  biceps,  two  heads;  /,  triceps;  gr,  supraspinatus;  /r,  infraspinatus; 
J,  subscapularis;  k,  humerus;  I,  acromion  process;  7n,  coracoid  process;  n,  coraco- 
acromial  ligament  (Scudder). 


old-fashioned  method,  often  useful,  is  for  the  surgeon  to  pry  back  the 
bone  into  the  socket  with  his  unbootecl  foot  placed  in  the  axilla. 

Theodor  Kocher's  method  of  reducing  a  dislocated  shoulder  is  the 
best  method,  and  is  in  common  use.^  Ceppi,  a  pupil  of  Kocher,  gives 
the  following  rule:    ''In  the  subcoracoid  dislocation  the  posterior  por- 


1  Revue  de  Chirurgie,  1882,  p.  831. 


59 


930 


MINOR    SURGEKY — DISEASES    OK    STRUCTUKE 


tion  of  the  capsule  and  the  tendons  of  the  posterior  scapidar  muscles 
which  cover  and  stren<;then  it  are  vmtorn  and  ai-e  stretched  over  the 
glenoid  fossa.     The  inferior  portion  of  the  capsule  which  forms  the 


tt 


arm 

Fig'.  (rj5. — Reducing  dislocation  of  the  shoulder.  Note  shoulder  over  edge  of 
table;  patient  on  back.  First  step:  Elbow  at  side.  Note  method  of  grasping  above 
elbow  and  wrist  (Scudder). 

lower  border  of  the  rent  is  also  very  tense.  But  the  tension  is  greatest 
at  the  upper  part  of  the  capsule,  and  especially  between  the  long  tendon 
of  the  biceps  and  the  upper  border  of  the  subscapularis,  where  it  is 


Fig.  636. 


-Second  step:  Elbow  at  side.     Rotation  of  forearm  outward  to  the  extreme 
limit  of  rotation  (Scudder). 


reinforced  by  the  fibers  of  the  coracohumeral  ligament.  This  portion 
of  the  capsule  is  twisted  in  the  dislocation,  and  stretched  in  the  foi'm  of  a 
solid  cord.  If  now,  the  humerus  is  rotated  externally  until  the  flexed 
forearm  is  turned  directly  outward,  this  cord  will  be  at  the  s:ime  time 


SPECIAL   DISLOCATIONS 


931 


rotated  outward,  the  posterior  part  of  the  capsule  will  be  widely  re- 
moved from  the  fossa^  and  the  rent  in  the  capsule  will  gape;  but  the 
head  of  the  humerus  will  still  remain  solidly  fixed  against  the  anterior 
edge  of  the  glenoid  fossa,  because  the  upper  and  lower  portions  of  the 
capsule  have  not  been  relaxed  by  this  movement.  It  is  only  when  the 
elbow  is  carried  fonvard  and  raised  in  the  sagittal  plane,  while  the  arm 
is  still  held  in  external  rotation,  that  the  upper  part  of  the  capsule  is 
seen  to  relax,  and  the  head  of  the  humerus,  thanks  to  the  tension  of 
the  lower  portion,  which  keeps  it  from  moving  fonvard,  to  enter  the 
socket.     Rotation  inward  then  completes  the  reduction." 


Fig.  637. — Third  step:  "While  external  rotation  is  maintained,  traction  downwai'd 
is  made  and  at  the  same  time  the  elbow  is  carried  in  adduction  to  the  midline  of 
body  (Scudder). 


Old  unreduced  dislocations  of  the  shoulder  offer  some  of  the  most 
difficult  of  surgical  problems.  We  never  know  the  limit  of  time  which 
must  prohibit  an  attempt  at  reduction  in  a  given  case.  Sometimes 
a  shoulder  dislocated  for  six  weeks  may  be  reduced  successfully;  again 
a  shoulder  dislocated  for  three  weeks  may  resist  ail  attempts  at  reduc- 
tion. Moreover,  if  the  surgeon  be  dealing  with  old  and  brittle  bones, 
he  runs  the  risk  of  causing  a  fracture  of  the  humerus,  while  he  fails  to 
reduce  the  dislocation.  For  such  reasons  the  operation  of  reduction 
must  be  undertaken  cautiously,  and  the  patient  must  be  forewarned 


932  MINOK    SUltGEUY — DISEASES   OF   STRUCTURE 

of  its  possible  outcome.  Kocher'.s  method  of  reduction  offers  to  the 
surgeon  so  firm  a  leverage  in  his  manipulations  of  the  humerus  that  he 
must  use  special  precaution  when  employing  this  method.  He  must 
resist  the  temptation  violently  to  rotate  the  humerus.  Perhaps  the 
safest  method  in  these  old  cases  is  the  ancient  method  of  traction,  and 
manijjulations  of  the  head  of  the  bone  by  an  assistant,  the  patient  being 
under  an  anesthetic,  of  course.  If  the  surgeon  fail  in  his  attempts  at 
reduction  after  a  reasonable  trial,  and  if  the  patient  consent,  the  opera- 
tor is  justified  in  cutting  down  upon  the  joint  and  in  lifting  the  bone 
back  into  place  if  possible;  or  he  may  even  think  it  wise  to  excise  the 
head  of  the  humerus  so  as  to  establish  a  false  joint. 

Dislocation  of  the  elbow  is  a  not  infrequent  accident.  Commonly, 
both  bones  of  the  forearm  are  dislocated  backward  behind  the  condyles 
of  the  humerus.     The  lesion  usuall}'  is  obvious.     The  olecranon  is  seen 


Fig.  638. — Fourth  step:  While  traction  is  being  made,  rotation  inward  is  made  of  the 
arm  by  placing  hand  upon  opposite  shoulder  (Scudder). 

and  protrudes  backward,  while  any  motion  in  the  joint  is  absolutely 
prohibited  miless  the  patient  be  anesthetized  when  one  finds  that 
lateral  mobility  exists.  I  referred  to  this  injuiy  in  discussing  the 
fractures  about  the  elbow-joint,  and  pointed  out  that  fractures  may 
be  associated  with  dislocations.  The  head  of  the  radius  also  alone 
may  be  dislocated  when  there  appears  the  characteristic  deformity. 

The  treatment  of  elbow  dislocations  is  simple  enough  when  the  dis- 
location is  recent,  but,  as  has  been  so  well  said  by  Stimson,  "in  the 
reduction  of  any  dislocation  the  displaced  bone  should  be  reduced  by 
the  path  along  which  it  came  when  dislocated.  A  haphazard  method 
of  reduction  of  a  dislocation  is  unsurgical."  "When  the  elbow  disloca- 
tion is  uncomplicated,  use  two  steps  for  its  reduction:  First,  extend 
completely  the  forearm,  which  frees  the  coronoid  from  the  olecranon 
fossa  and  the  posterior  surface  of  the  humems;   second,  employ  firm 


SPECIAL   DISLOCATIONS 


933 


traction  upon  the  forearm  and  flex  it,  when  the  bones  slip  back  into 
place.     The  reduction  being  completed,  put  up  the  arm  in  an  internal 


Fig.  639.— Showing  a  method  of  reduction  of  a  dislocation  of  the  elbow  back- 
ward. *Xote  partial  extension  of  forearm  on  arm;  position  of  thumbs  of  surgeon 
behind  olecranon  making  pressure  forward  while  fingers  make  pressure  backward 
(Scudder). 

angular  splint  for  two  or  three  days,  after  which  remove  the  splint, 
bandage  the  arm,  and  massage  it  as  I  have  already  described.     V^e 


Yia-  640  —Old  dislocation  of  the  head  of  the  radius  outward  and  backward. 
Functional  usefulness  of  the  elbow  unimpaired.  Pronation  and  supination  normal. 
In  such  a  dislocation,  were  there  present  any  serious  disability,  excision  ot  the  head 
of  the  radius  would  be  indicated  (Codman)      (Scudder). 

should  expect  a  useful  and  sound  elbow  after  three  weeks  of  such,  treat- 
ment. 


934  MINOR   SURGKUY — DISEASES    OF   STRLCTIKE 

Old  unreduced  dislocations  of  the  elbow  arc  almost  impossible  of 
reduction,  so  that  our  one  resource  in  these  cases  is  an  operation.  We 
should  use  that  method  which,  with  the  least  damage  to  the  joint, 
exposes  all  the  affected  bones,  and  we  can  usually  accomplish  this 
through  cutting  down  upon  the  parts  from  behind,  or,  if  we  prefer, 
through  Kocher's  lateral  incision.  Sometimes  we  nmy  advance  most 
successfully  by  removing  the  olecranon.  We  then  trim  away  all 
adventitious  and  frayed  tissue  and  reduce  the  dislocation.  If  the 
articular  surfaces  appear  nonnal.  we  may  look  for  the  restoration  of  a 
useful  joint;  if,  however,  the  joint  surfaces  are  damaged,  and  if  there 
be  loss  of  substance  in  the  articular  cartilages,  it  may  be  wise  to  per- 
form arthroplasty  after  the  method  of  J.  B.  Murphy — the  insertion 
within  the  joint  of  a  fat-fascial  flap  taken  from  the  posterior  surface 
of  the  arm.  In  some  extreme  cases  it  may  be  wise  to  do  a  partial  or 
complete  excision  of  the  joint.  After  any  of  these  operations  we  can 
scarcely  look  for  a  restoration  of  normal  function,  but  we  may  expect 
fair  motion  and  a  reasonal)h'  strong  arm. 


Fig.  641. — Backward  dislocation  of  first  phalanx  of  tliumb.  Note  head  of 
metacarpal  and  how  it  is  held  by  adductor  brevis  and  flexor  longus  poliicis  (Helf- 
erich). 

Dislocations  of  the  wrist  call  for  no  special  mention.  They  are 
obvious;  they  are  easily  reduced  if  fresh,  while,  if  old  and  fixed,  they 
may  best  be  treated  by  a  partial  excision  of  the  wrist. 

Backward  dislocation  of  the  first  proximal  phalanx  of  the 
thumb  is  often  found  to  be  extremely  difficult  of  reduction.  The  two 
lateral  ligaments  are  torn,  and  the  phalanx  slips  backward  and  over 
the  head  of  the  first  metacarpal  bone.  Ordinarily,  we  increase  the 
difficulty  by  making  traction.  We  must  manipulate  the  bone  back 
into  place  by  extending  completely  the  thumb,  so  as  to  relax  the  tendons 
of  the  adductor  brevis  and  flexor  longus  poliicis,  and  then  push  the  base 
of  the  phalanx  fonvard,  advancing  at  the  same  time  the  torn  glenoid 
ligament  over  the  end  of  the  metacarpal  bone;  we  then,  by  flexion, 
complete  the  reduction,  and  dress  the  thumb  on  the  proper  fixation 
splint. 

The  other  bones  of  the  hand  are  subject  to  dislocations  which  may 
easily  be  reduced  and  held  in  place. 


SPECIAL   DISLOf'ATIONS 


935 


Dislocations  of  the  Hip.— Forty  years  ago  the  subject  of  hip 
dislocations  avus  one  of  prime  interest  to  surgeons  and  to  medical 
students,  for  in  those  days  Heniy  J.  Bigelow  was  investigating  and 
writing  upon  this  interesting  topic.  The  genius  of  the  man  illumin- 
ated and  made  conspicuous  the  theme.  In  fact,  dislocations  of  the  hip 
are  extremely  rare,  and  most  physicians  will  live  through  a  lifetime  of 
practice  without  seeing  one.  So  rare  and  so  interesting  is  the  condition 
that  to-day  even  at  the  Massachusetts  General  Hospital,  where  Bigelow 
conducted  his  clinical  investigations  on  the  subject,  a  dislocated  hip  is 
still  regarded  as  a  precious  curio,  which  must  not  be  reduced  by  the 
casual  house-surgeon,  but  must 
be  reserved  for  the  inspection 
and  treatment  of  the  visiting 
surgeon  himself. 


Fig.  642.— The  Y-ligament  (Bigelow).       Fig. 


643. — Location   of   head   in   various 
forms  of  dislocation  of  hip. 

Bigelow's  studies  and  explanation  of  hip-joint  dislocations  are  of 
especial  interest,  because  he  was  able  satisfactorily  to  demonstrate  how 
it  is  that  the  anterior  portion  of  the  capsule  of  the  hip-jomt  forms  a 
strong  band  shaped  like  an  inverted  Y,  which  obstructs  the  return  of 
the  dislocated  bone  into  its  socket,  when  the  old-time  method  of  reduc- 
tion is  used.  Bigelow  demonstrated  that  this  Y-Iigament,  as  he  called 
it,  may  well  be  used  as  a  fulcrum,  upon  which  the  surgeon  may  rely 
to  assist  him  in  reducing  hip  dislocations  by  simple  methods  of  manipu- 
lation. Surgeons  other  than  Bigelow  had  reduced  hip  dislocations 
by  somewhat  similar  maneuvers,  notably  Little,  of  Texas,  and  Reed, 
of  Rochester,  N.  Y.,  in  this  country,  and  various  others  m  Europe;  but 
it  remained  for  Bigelow,  and  later  for  Allis,  to  put  manipulation  methods 
upon  a  rational  basis. 


93G 


MINOR   SURGERY — DISEASES   OF   STRUCTURE 


Scudder  ^  briefly  and  lucidly  sums  up  the  anatomy  and  mechanism 
of  hip-joint  dislocations  in  the  following  words:  "A  line  tlrawn  from 
the  anterior  superior  spinous  process  of  the  ilium  to  the  tuberosity  of 
the  ischium  passes  about  midway  across  the  acetabulum.  The  portion 
of  the  bony  pelvis  posterior  to  this  line  is  called  the  outer  plane  of  the 
pelvis.  The  portion  of  the  pelvis  anterior  to  this  line  is  called  the 
inner  plane  of  the  pelvis  (Allis).  The  hip  is  dislocated  by  a  force 
bringing  leverage  to  bear  upon  the  hip  bone  when  the  thigh  is  Hexed 
upon  the  abdomen.  The  head  of  the  femur  leaves  the  acetabulum 
through  a  rent  in  the  under  portion  of  the  capsule  of  the  joint. 

"The  first  movement  of  the  head  in  being  dislocated  is  downward. 
According  as  the  head  of  the  bone  slips  to  the  outer  or  the  inner  plane 
of  the  pelvis  wall  the  dislocation  be  classified  as  an  outer  or  an  inner  dis- 
location, that  is,  a  posterior  or  an  anterior  dislocation.  Of  course,  in 
either  position,  whether  the  outer  or  the  inner,  the  head  of  the  bone  may 


Fig.  644.— Hip- 
joint  dislocation  on 
to  the  dorsum  of 
the  ilium  (Cooper;. 


Li- 


Fig.  645. — Hip- 
joint  dislocation 
into  the  sciatic 
notch  (Cooper). 


Fig.  646.— Hip- 
joint  dislocation 
into  the  obturator 
or  thyroid  foramen 
(Cooper) . 


Fig.  647.- 
cation  on 
(Cooper). 


-Dislo- 

pubis 


be  high  up  or  low  down.  The  anterior  portion  of  the  capsule  of  the 
hip-joint  is  far  thicker  than  any  other  portion  of  the  capsule.  This 
thickened  portion  Bigelow  called  the  Y-ligament." 

Surgeons  have  for  years  subdivided  the  class  of  anterior  dislocations 
into  dislocations  into  the  obturator  foramen  and  dislocations  upon  the 
pubis;  while  the  common  posterior  dislocation  is  classified  as  a  disloca- 
tion upon  the  dorsum  of  the  ilium — "dorsal  dislocation."  Dislocation 
into  the  sciatic  notch  is  a  posterior  dislocation  also,  and  may  be  regarded 
as  a  rather  exaggerated  form  of  dorsal  dislocation. 

The  signs  and  symptoms  of  inward  or  anterior  dislocations  are  as 
follows:  The  thigh  is  flexed  upon  the  abdomen,  abducted  and  rotated 
outward,  while  the  heel  is  raised  and  the  foot  is  everted.  In  the  case 
of  an  outward  or  dorsal  dislocation,  the  limb  is  inverted,  somewhat 
shortened,  and  flexed  slightly,  while  the  toes  rest  upon  the  instep  of  the 
i  C.  L.  Scudder,  ibid.,  p.  603. 


SPECIAL   DISLOCATIONS 


937 


sound  foot.  The  interesting  figures  taken  from  Astley  Cooper's  classic 
work  represent  admirably  the  appearances  of  these  various  disloca- 
tions. 

If  the  surgeon  will  but  bear  in  mind  the  position  of  the  Y-ligament, 
which  extends  from  the  anterior  inferior  spine  of  the  ilium  to  the  line 
below  the  two  trochanters  of  the  femur,  and  if  he  will  reflect  that  this 
ligament  forms  a  fulcrum  about  which  the  head  of  the  bone  revolves  in 
dfslocations,  he  will  perceive  readily  the  directions  in  which  the  head 
must  be  turned  in  order  to  reduce  the  various  dislocations.  _  The  old 
cuts  from  Bigelow's  well-known  work  illustrates  these  anatomic  poiiits. 

Treatment.— In  order  to  reduce  an  inward  or  anterior  dislocation 
we  may  observe  one  of  the  following  methods: 


-Dorsal   dislocation    (Bige- 
low). 


Fig.   649. — Obturator      dislocation 
(Bigelow). 


Bigelow's  method  of  reduction  of  obturator  or  anterior  dislocations: 
The  surgeon  flexes  the  thigh  on  the  abdomen  to  a  right  angle,  abducts 
it,  rotates  it  inward  with  adduction,  and  then  extends  it  vigorously, 
when  the  bone  should  slip  into  place. 

Allis's  indirect  method:  Extension,  adduction,  and  outward  rota- 
tion are  the  movements  made.  We  place  the  patient  on  a  blanket 
upon  the  floor  and  flex  the  femur.  The  surgeon  then  supports  tlie 
flexed  knee  upon  his  own  bent  elbow,  and  grasps  the  ankle  with  his 
other  hand;  he  then  extends  the  latter  with  traction  m  the  line  of  the 
long  axis 'of  the  femur,  adducts,  and  rotates  outward.     _  _ 

Needless  to  say,  in  all  manipulations  for  the  reduction  of  hip  dis- 
locations the  patient  should  be  profoundly  anesthetized. 

The  reduction  of  outward  or  dorsal  dislocations:  If  the  case  be 
uncomplicated,  the  surgeon  may  properly  follow  the  directions  of 
Stimson.     Lay  the  anesthetized  patient  on  his  belly  upon  a  table,. 


938 


MINOR   SURGERY — DISEASES   OF   STRUCTURE 


with  both  his  legs  protruding  their  length  bc^'ond  the  table.  An 
assistant  holds  up  the  sound  leg,  while  the  damaged  leg  is  allowed  to 
drop.  The  surgeon  now  grasps  the  affected  leg  and  flexes  the  knee  to 
a  right  angle,  when  the  weight  of  the  leg  itself,  pulling  upon  the  muscles 
about  the  hip,  aided  by  a  little  pressure  and  rotation  on  the  part  of  the 
surgeon,  promptly  reduces  the  dislocation. 

The  methods  of  Allis  and  Bigelow  in  the  case  of  a  dorsal  disloca- 
tion are  somewhat  similar  to  each  other  and  differ  radically  from  the 
method  I  have  just  described,  in  that  reduction  is  effected  while  the 
patient  lies  upon  his  back,  when  the  dislocated  femur  is  lifted  up  into 
place. 

(1)  Allis'  method:  The  patient  lies  on  a  blanket  on  the  floor,  his 
pelvis  held  firmly  by  assistants,  while  the  surgeon  kneels  at  his  side 
and  flexes  and  elevates  the  leg  with  his  OAvn  arm  beneath  the  patient's 
knee;   he  now  turns  the  bent  leg  outward,  lifts  the  leg   inward  and 

rapidly  extends  and  <lrops  the  whole  limb 
upon  the  floor,  Ijy  which  maneuver  he 
effects  reduction. 

(2)  Bigelow's  method  for  the  reduc- 
tion of  a  dorsal  dislocation:  The  patient 
lies  upon  his  back  on  a  blanket  upon  the 
floor;  the  surgeon  flexes  the  affected 
thigh  with  his  own  elbow  beneath  the 
knee,  adducts  the  limb,  inverts  it  slightly, 
lifts  it,  circumducts  the  leg  outward,  and 
then  strongly  extends  and  drops  it,  when 
reduction  should  be  found  complete. 

Observe  that  these  maneuvers  are  not 
always  immediately  successful.  They  are 
successful  if  the  capsule  be  widely  torn 
and  if  there  be  no  soft  parts  to  interfere 
with  rotation  of  the  bone  back  into  its 
socket.  Furthermore,  long-standing  dis- 
locations may  be  found  impossible  of  re- 
duction by  these  methods  on  account  of 
a  partial  closure  of  the  rent  in  the  joint's 
capsule.  If  he  finds  it  impossible  to  re- 
duce a  hip-joint  dislocation  by  manipulative  measui'es,  the  surgeon 
should  cut  down  upon  it  through  a  long  incision  over  the  great 
trochanter;  should  free  the  head  of  the  bone;  should  investigate 
the  joint,  and  should  return  the  head  to  its  socket,  under  easy  in- 
spection. 

If  one  has  reduced  the  bone  without  a  cutting  operation,  he  should 
confine  the  patient  to  bed  for  at  least  two  weeks,  after  which  he  may 
carry  on  the  treatment  by  the  use  of  crutches,  massage,  passive  motions, 
and  the  gradual  reemployment  of  the  limb;  six  weeks  at  least  must 
elapse  before  the  patient  can  walk  with  reasonable  comfort.  If  the 
surgeon  is  forced  to  cut  down  upon  the  joint  in  order  to  reduce  a  dis- 


—  Pubic      dislocation 
(Bigelow). 


SPECIAL    DISLOCATIONS 


939 


location,  a  longer  and  more  tedious  convalescence  will  follow,  though 
with  proper  asepsis  and  with  sound  wound  healing  the  c^uestion  of  con- 
valescence will  be  one  of  time  only,  and  not  of  aii}'  material  variation 
in  the  treatment. 

The  patella  is  sometimes  dislocated.  The  accident  occurs  through 
a  blow  upon  the  inner  side  of  the  knee,  forcing  the  patella  out  of  plumb, 
and  carrying  it  over  the  edge  of  the  femoral  condyle  even.  If  the 
patella  rests,  balancing  upon  the  condyle,  we  call  the  condition  subluxa- 
tion. A  curious  and  more  unusual  form  of  dislocation  is  that  spoken 
of  as  vertical  rotation,  in  which  case  the  patella  is  turned  up  on  its  edge. 
The  mechanism  of  these  various  displacements  is  obvious,  and  the 
treatment  is  the  most  simple  conceivable.  Often  it  is  necessary  merely 
to  anesthetize  the  patient  and  lift  the  leg  toward  the  abdomen,  when 
the  patella  at  once  falls  back  into  place.  If  it  does  not  spontaneously 
retreat,  it  can  easily  be  manipulated  back  into  its  normal  bed. 


Fig.  651. — Outward  dislocation  of  the  patella  (Hoffa). 

A  good  deal  of  swelling  and  pain  may  follow  the  reduction,  but  this 
subsides  in  a  few  days  under  bandaging  and  massage. 

The  knee  is  dislocated  rarely.  Theoretically,  the  knee  may  be 
dislocated  in  any  direction,  backward  or  forward,  right  or  left,  though 
the  backward  displacement  of  the  tibia  on  the  femur  is  the  most  com- 
mon form  of  displacement.  Those  forms  of  subluxation  of  the  tibia 
which  are  associated  with  tuberculous  disease  of  the  knee-joint  illus- 
trate a  common  picture  of  dislocations  of  the  knee. 

A^Tien  the  femur  underrides  the  head  of  the  tibia,  we  find  the  patella 
forced  upward  out  of  its  close  association  with  the  femoral  condyles. 
In  this  way  there  is  produced  a  double  dislocation  or  a  dislocation  of 
two  joints,  as  it  were — the  tibia  from  the  femur  and  the  femur  from 
the  patella.     It  is  obvious  in  the  form  of  dislocation,  such  as  Lothrop 


940  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

reports,  that  the  patella  must  leave  the  femur,  for  the  patella  is  attached 
closely  to  the  head  of  the  tibia  by  the  strong  ligamentum  patella?. 

We  can  usually  reduce  knee  dislocations  readily  ])y  the  eniploj'ment 
of  strong  traction  and  niunii)uhiti()n,  the  patient  being  anesthetized. 

Occasionally  the  semilunar  cartilages  are  torn  loose  and  displaced 
— sometimes  displaced  so  far  as  to  project  over  the  margin  of  the  tibia. 
I  shall  refer  to  this  matter  later  in  our  brief  discussion  of  bone  and 
joint  diseases.  Suffice  it  here  to  state  that  the  loosened  semilunar 
cartilage  had  best  be  removed. 

After  all  these  injuries  to  the  knee-joint  the  limb  must  be  kept 
at  rest  on  a  splint  until  exudation  has  subsided  and  the  movements 
of  the  joint  can  be  produced  without  especial  distress.  A  patient  in 
good  health  should  recover  perfectly  the  use  of  the  knee-joint  after 
dislocation  in  the  course  of  from  six  weeks  to  two  months. 

Dislocations  of  the  Bones  of  the  Foot. — An  ankle-joint  is  some- 
times dislocated,  though  this  injury  is  much  more  rare  than  popular 
statement  asserts — I  mean  a  dislocation  without  a  fracture.  We  have 
seen  that  a  dislocation  outward  of  the  ankle  is  a  common  accompani- 
ment of  Pott's  fracture.  Simple  dislocations  of  the  ankle  are  extremely 
rare,  however,  on  account  of  the  solid  mortising  of  the  joint.  When 
such  dislocations  do  occur,  however,  they  are  associated  with  an  exten- 
sive laceration  of  the  joint  ligaments.  Alwaj's  make  sure  that  there  is 
no  fracture  i3resent. 

Rarely  the  other  bones  of  the  tarsus,  the  os  caJcis,  and  the  scaphoid 
may  be  forced  out  of  place  by  strongly  applied  direct  violence,  but  it  is 
most  uncommon  to  find  these  dislocations  except  when  they  are  associ- 
ated with  extensive  lacerations  and  fractures  of  other  bones.  The 
metatarsal  bones  and  the  phalanges  of  the  foot  likewise  may  be  dis- 
located. 

The  treatment  of  all  these  dislocations  at  the  ankle-joint  and  below 
it  is  obvious.  The  surgeon  should  have  proper  x-raj's  taken  to  ascertain 
the  exact  nature  of  the  damage,  and  then,  having  determined  that  no 
fracture  or  other  untoward  complicating  lesion  is  present,  he  should 
manipulate  back  into  place  the  displaced  bones  and  should  apply  a 
carefully  padded  bandage  for  two  or  three  days.  Then  he  should 
employ  massage.  There  are  no  joints  of  the  body  perhaps  which 
demand  so  emphatically  the  use  of  massage  for  their  restoration  of 
function.  Every  joint  of  the  foot  is  a  weight-bearing  joint;  the  force 
brought  to  bear  upon  it  in  every -day  life  is  extremely  great;  it  will 
not  answer  to  treat  such  a  joint  lightly,  or  to  assume  its  ready  healing 
under  the  old-fashioned  methods  of  immobilization.  A  damaged  joint 
of  the  foot  must  be  taken  in  hand  from  the  beginning,  and  must  be 
massaged  and  manipulated  thoroughly,  and  watched  carefully,  until 
convalescence  is  established. 

Dislocations  of  the  Lower  Jaw. — Obviously,  a  dislocation  of  the 
upper  jaw  is  an  impossibility,  so  that  all  dislocations  of  the  jaw  are 
dislocations  of  the  lower  jaw.  The  books  furnish  us  with  descriptions 
of  manifold  types  of  jaw  dislocations.     As  a  fact,  nearly  all  dislocations 


SPECIAL  DISLOCATIONS 


941 


of  the  jaw  are  dislocations  forward.  To  be  sure,  there  is  the  dislocation 
backward  accompanied  by  fracture,  a  lesion  so  complicated  and  difficult 
of  adjustment  that  usually  the  surgeon  is  obliged  to  cut  down  upon  the 
damaged  bones,  and  either  wire  and  reduce  them,  or  more  commonly 
remove  the  head  of  the  bone  and  endeavor  to  institute  a  false  joint. 
Certain  writers — LeFevre,  Robert,  Xeis,  and  a  few  others — have  reported 
rare  dislocations  of  the  jaw  upward  and  outward,  but  these  anomalies 
need  concern  the  student  but  little.  The  common  foi'ward  dislocation 
of  the  lower  jaw  is  usually  caused  by  muscular  action — by  laughing, 
yawning,  or  vomiting,  or  rarelj'  by  a  violent  blow  upon  the  angle  of  the 
jaw  from  behind,  when  the  victim  had  his  mouth  open.  The  mechan- 
ism of  the  dislocation,  is,  therefore,  simple  enough,  but  the  relation  of 
the  parts  after  dislocation  has  not  been  so  obvious.      The  capsule  is 


Fig.  652. — Double  dislocation.  Note  open  mouth;  displaced  articular  process; 
enipty  glenoid.  Capsule  uninjured;  temporal  muscle  taut  (after  Helferich)  (Scud- 
der). 

not  necessarily  torn,  though  it  may  be.  It  is  always  tightly  stretched, 
while  as  a  reflex  result  the  temporal  muscle  is  thrown  into  a  condition 
of  tonic  spasm,  by  which  the  jaw  is  fixed,  and  firmly  held  in  its  abnormal 
position  outward  and  forward.  As  a  result  of  the  position  of  the  bone 
and  the  displacement  of  the  coronoicl  process,  the  mouth  is  forced  widely 
open  and  thus  held,  while  the  chin  is  markedly  protruded.  The  dis- 
location may  be  either  one-sided  or  bilateral,  but  in  both  cases  the 
deformity  is  practically  the  same. 

Reduction  of  jaw  dislocations  is  simple  and  easy  when  properly  under- 
taken— that  is  to  say,  when  the  patient  is  thoroughly  relaxed  by  an 
anesthetic.  Perhaps  in  the  case  of  no  other  dislocation  is  a  thorough 
relaxation  so  important.  I  learned  this  as  a  student  while  endeavoring, 
in  the  accident  ward  of  the  hospital,  to  reduce  the  dislocated  jaw  of  a 


942 


MINOR    SURGERY — DISEASES    OF    STRUCTURE 


man  imperfectly  etherized.  I  could  make  no  impression  whatever 
on  the  dislocation,  but  a  senior  surgeon,  chanchig  to  go  by,  pushed 
the  ether  until  the  patient  was  completely  relaxed,  when  the  head  of 
the  bone  slipped  back  into  its  socket  almost  at  a  touch. 

Our  sketch  shows  the  method  of  reducing  a  dislocation  of  the  jaw. 
After  its  reduction  the  bone  shoidd  be  held  in  place  for  three  or  four 
days  by  a  four-tailed  bandage,  and  the  patient  should  not  be  allowed 
to  chew  until  the  soreness  has  nearly  disappeared. 


Fig.  653. — Method  of  reduction  of  dislocation  of  the  jaw.  I5oth  thumbs,  having 
been  covered  witli  several  turns  of  a  roller  bandage,  are  inserted  into  the  mouth  over 
the  molar  teeth,  the  fingers  of  both  hands  being  placed  on  the  outer  side  of  the  jaw. 
Pressure  is  made  in  a  downward  direction  by  both  thumbs,  as  described  in  the  text 
(Eisendrath). 

We  have  now  discussed  the  more  important  dislocations  which  are 
seen  in  every-day  private  and  hospital  practice.  There  are  other  and 
rarer  forms  of  displacements  of  bone — of  bones  seldom  dislocated,  of 
bones  dislocated  by  spontaneous  muscular  action,  of  bones  habitually 
dislocated;  but  the  treatment  of  such  conditions  must  be  obvious  to 
the  student  who  has  once  grasped  the  principles  we  have  studied  in  this 
chapter. 


CHAPTER  XXX 
BONES  AND   JOINTS    (ORTHOPEDIC   SURGERY) 

Thf  sui-'-eiy  of  the  bones  and  joints  is  the  most  ancient  chapter  of 
sui-oeiy  kno\vn  to  us.     Orthopedic  '  surgery— that  is  to  say,  surgery 
whidi  deals  with  deformities  is  a  reh^tively  modern  branch  of  the  art 
of  surgery.     Ahhough  orthopedic  surgery  concerns  itself  with  struc- 
tures other  than  bones,  at  the  same  time  the  greater  portion  of  its 
interest  is  with  bones,  so  that  it  seems  well  to  me  to  consider  some 
phases  of  orthopedics  m  this  chapter  in  connection  with  the  subject 
of  diseases  of  the  bones  and  joints.     Orthopedic  surgery  has  been  de- 
veloped   in  America,  into  a  great  and  special  art,  with  an  enormous 
literature  of  its  own,  and  ponderous  text-books.     Obviously,  therefore, 
it  would  be  impossible,  if  not  improper,  for  us  in  this  place  to  take  up 
at  lenoth  the  numerous  questions  with  which  orthopedic  surgery  is 
concerned.     Thev   are  within  the  province  especially  of  orthopedic 
^uro-eons.     At  tlie  same  time  the  student  and  the  general  practitioner 
must  deal  frequently  with  certain  of  the  more  famihar  forms  of  ortho- 
pedic lesions.     Such  lesions  I  shall  describe  briefly  m  the  fpllowmg 
pages,  taking  them  up  incidentally,  perhaps,  m  connection  with  bone 
and  joint  diseases. 

THE  BONES 

The  surgery  of  bones  began  to  find  development  in_  remote   times 
because  bone  lesions  were  common,  or  reasonably  obvious,  and  were 
vital  to  the  phvsically  active  peoples  of  early  days.     Fractures  especia  ly 
enorossed  the  attention  of  ancient  surgeons,  and  we  learn  from  the 
wntino-s  of  the  E^vptians  and  of  the  Jews  that  fracture  surgery  had 
attained   a   remai'kable   degree   of   development   thousands   of   years 
before  our  era.     We  have  discussed  fractures  m  a  previous  chapter; 
let  us  therefore  at  present  consider  more  especially  certam  bone  cbseases. 
\s  Roswell  Park  remarks,  we  must  bear  in  mmd  the  fact  that  tlie 
osseous  system  is  subject  to  much  the  same  diseases  as  affect  the  softer 
sti-uctures  of  the  human  frame.     Bone  is  a  tissue;  it  becomes  inflamed, 
it  deo-enerates,  it  hvpertrophies,  it  is  the  seat  of  tumors.     Moreover, 
bones  are  complex  structures;   they  are  vascular;   they  are  of  varymg 
hardness  ;Mhev  have  differing  densities,  and  we  apply  to  the  parts  ot 
bone  the  familiar  terms  cancellated,  ivory,  medulla,  enc  osteum   peri- 
osteum, and  marrow-all  of  which  terms  must  be  well  known  to  the 
reader      Moreover,  special  bones  are  adapted  to  special  purposes.     \A  e 
recognize  the  peculiar  lightness,  resiliency,  and  strength  of  the  dome- 

1  bpdoc,  straight;  ^^a/s  child. 

943 


944  MixoR  SURGERY — disp:ases  of  stiutture 

shaped  bones  of  the  .-^kull,  ^vhile  the  intricule  structure  of  the  upper  por- 
tion of  the  femur  has  long  been  the  uchnii'jition  of  intelhgent  architects. 
The  reader's  studies  in  embr^'ology  have  ah't'ad}'  taught  him  some- 
thing of  the  growth  and  structure  of  young  bones;  ancl  we  recall  the 
fact  that  the  developing  bone  of  the  child  and  youth  may  be  quite 
different  in  its  construction  from  the  firm  bone  of  the  adult.  Especially 
must  we  bear  in  mind  alwaj-s,  when  dealing  with  j'oung  bones,  that  they 
are  in  process  of  formation;  that  their  centers  of  ossification  are  still 
separated,  and  that  their  epiphyses  may  have  but  the  frailest  of  attach- 
ments to  the  long  and  firm  diaphyses. 

Nichols^  divides  the  lesions  of  bone  into  five  classes:  (1)  Those 
lesions  produced  1)}'  vaiious  pathogenic  organisms;  (2)  those  which 
are  apparently  due  to  some  diathesis — e.  g.,  rickets,  acromegaly;  (3) 
lesions  produced  by  disuse — atrophy;  (4)  tumors  of  bone;  (5)  cysts, 
which  may  be  primary  or  may  be  due  to  the  presence  of  echinococci. 

Let  us  consider  first  certain  congenital  conditions  or  defects  in  the 
bones.  Bearing  in  mind  that  human  bones  are  preformed  in  cartilage, 
we  can  understand  how,  through  an  interference  with  the  normal 
formation  of  this  cartilaginous  mass,  the  final  condition  developed 
may  be  retarded,  or  may  be  turned  in  a  wrong  direction.  Occasionally 
we  find  that  a  whole  bone  is  lacking.  This  is  curiously  illustrated  by 
the  well-known  case  of  Lund,  which  was  published  by  that  surgeon 
some  years  ago,  and  has  frequently  been  reproduced. 

On  the  other  hand,  the  reverse  of  this  process  is  seen,  namely,  an 
abnormal  number  of  cartilaginous  masses  ma}'  be  deposited  and  may 
be  developed  into  bones,  in  which  case  we  find,  for  example,  super- 
fluous limbs  or  parts  of  limbs.  The  six-fingered  hand  is  a  familiar 
example  of  this — the  so-called  polydactylism;  or  there  may  be  a  per- 
version of  development  of  these  extra  bones,  resulting  in  curious  com- 
binations of  fingers,  producing  the  well-known  condition  known  as 
syndactylism.  It  is  needless  to  multiply  examples  of  these  conditions, 
which  are  familiar  to  all  surgeons. 

Bones  are  subject  to  atrophy,  as  are  other  anatomic  structures; 
and  we  know  that  various  causes  lead  to  bone  atrophy.  In  the  case 
of  old  persons  bone  atrophy,  or  "lacunar  resorption,"  is  often  ver}- 
great,  and  has  received  the  clinical  term  "senile  atrophy."  We  see 
it  in  the  skull  and  in  the  long  bones,  and  we  know  that  it  is  responsible 
for  the  frequent  fractures  of  the  long  bones  in  old  persons.  Disuse,  as 
well  as  old  age,  may  lead  to  "lacunar  resorption";  indeed,  we  see  such 
resorption  in  bone-stumps  after  amputation  and  in  cases  of  limbs 
paralyzed  by  some  central  nervous  disorder. 

Bones  are  subject  to  hypertrophy  also,  in  which  case  great  enlarge- 
ment of  the  bones,  either  of  the  skull  or  in  the  limbs,  may  take  place. 
Such  hypertrophy  may  be  due  to  a  new  formation  of  periosteal  bone 
in  its  attempts  at  repair,  or  the  process  ma}'  be  a  tiaie  hypertrophy 
in  no  way  associated  with  previous  destruction  of  bone.  Hypertrophy  is 
seen  sometimes  in  the  amputation  stumps  of  young  persons. 
•  E.  H.  Nichols,  in  Keen's  Surgerj',  vol.  ii,  p.  21. 


THE    KONEo  945 

Of  far  more  practical  interest  to  nurgcons,  however,  than  the  rather 
curious  and  unusual  conditions  which  1  have  described  are  the  familiar 
active  processes  in  bone  and  in  the  periosteum — especially  the  in- 
jiammalory  processes.  Of  these  processes,  usually  due  to  infections, 
one  of  the  most  familiar  is  periostitis.  E.  H.  Nichols  reminds  us  that 
the  older  text-books  always  laid  great  stress  upon  the  occurrence  of  an 
acute  infectious  inflammation  of  the  periosteum;  but  he  affirms  that 
in  his  opinion  acute  suppurating  periostitis  alone  does  not  occur,  and 
that  most  of  the  cases  so  described  are  really  mild  cases  of  superficial 
osteomyelitis,  with  abscess  formation  beneath  the  periosteum,  and 
possibly  inflammation  of  the  periosteum  itself. 

Periostitis  gives  rise  to  an  acute  localized  pain,  exquisite  tenderness, 
loss  of  function,  and  fever,  with  or  without  chills.  Untreated,  such 
cases  go  on  to  a  serious  and  extensive  involvement  of  the  whole  bone 
r.ffected.  For  this  reason  prompt  and  energetic  treatment  is  essential: 
free  incision  into  the  affected  area,  cleaning  out  the  cavity,  and  cleansing 
with  irrigation  and  packing  until  the  wound  has  healed  from  the  bottom. 
These  are  the  cases  of  the  so-called  acute  periostitis. 

On  the  other  hand,  we  recognize — 

Chronic  periostitis,  a  long-continued  irritation  of  the  periosteum, 
with  a  proliferation  from  the  bone-forming  cells  of  that  structure. 
Chronic  periostitis  is  a  sequel  and  an  associate  of  many  general  infec- 
tious diseases, — of  syphilis,  of  typhoid, — as  well  as  of  injuries  and 
long-standing  superficial  ulcerative  processes  (e.  g.,  varicose  ulcers). 
These  chronic  inflammations  may  or  may  not  give  rise  to  pronounced 
symptoms.  A  patient  may  experience  constant  dull  pain  and  loss 
of  power  in  the  part;  or  he  may  be  relatively  free  from  discomfort  and 
go  about  ignorant  of  the  true  condition.  Unfortunately,  we  cannot 
always  promptly  and  readily  treat  or  cure  a  chronic  periostitis.  We 
must  direct  our  attention,  of  course,  to  the  underlying  disease,  and  we 
must  remove  all  the  irritative  factors.  In  spite  of  us,  however^,  many 
of  these  cases  mn  on  in  an  indefinite  course,  little  affected  by  the  en- 
deavors of  the  enthusiastic  surgeon. 

Caries  and  necrosis  are  familiar  terms,  signifying  a  destruction  and 
death  of  bone.  Ordinarily  surgeons  regard  caries  as  due  to  a  tuberculous 
process,  which  brings  about  a  molecular  softening  and  destruction  of 
the  bone.  Ultimately,  this  process  may  be  extensive,  while  there  is 
present  at  no  time  any  appreciable  mass  of  dead  bone.  Necrosis,  on 
the  other  hand,  is  generally  due  to  some  pathologic  process,  which 
causes  the  death  of  large  bone  areas  at  once,  in  which  case  the  mass 
of  dead  bone  lies  like  a  foreign  body  encased  in  the  living  bone,  and^  is 
termed  a  ''sequestrum."  Clinically,  therefore,  we  distinguish  caries 
from  necrosis — the  former,  as  due  to  a  tuberculous  process ;  the  latter, 
as  due  to  an  acute  pyogenic  infection.  Caries  is  found  commonly 
in  the  neighborhood  of  joints  which  themselves  become  involved  in 
the  disease;  w^hile  necrosis  more  frequently  is  seen  in  the  shafts  of 
bones.  Both  caries  and  necrosis,  if  long  continued,  bring  about  an 
inflammation  of  neighboring  soft  parts,  the  destruction  more  or  less 

60 


946  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

of  overlying  tissues,  the  development  of  sinuses  leading  outward,  and 
the  establishment  of  chronic  running  sores. 

Modem  surgery  retains  the  words  caries  and  necrosis  merely  as 
clinical  terms  of  convenience.  AVe  shall  discuss  their  underlying  causes 
shortly  and  at  greater  length  in  our  paragraphs  on  osteomyelitis  and  on 
tuberculosis. 

Acute  osteomyelitis  is  one  of  the  most  urgent,  painful,  and  destruc- 
tive of  inflamnuitory  processes.  It  is  a  suppuration  of  bone,  and  is 
due  to  an  infection  of  the  bone-marrow^  by  pyogenic  organisms.  It  has 
been  called  "bone  fui"unculosis."  The  infection  may  involve  the 
entire  marrow  of  the  bone  affected.  Generally  the  active  organism 
concerned  is  the  Staphylococcus  pyogenes  aureus;  less  often,  the 
typhoid  bacillus,  the  streptococcus,  or  the  pneumococcus.  The  disease 
may  be  due  to  certain  general  causes  also — in  young  persons  whose 
bones  are  undeveloped;  in  persons  exhausted  from  long  illness,  from 
fatigue,  from  exposure;  and  especially  in  persons  the  subjects  of  acute 
general  infections.  Osteomyelitis  follows  upon  local  bone  injuries  also, 
which  diminish  the  resisting  qualities  of  the  bone;  such  injuries  especi- 
ally as  compound  fractures.  Osteomyelitis  begins  nearly  always  in 
the  diaphysis,  though  rarely  it  maj'  begin  in  the  epiphysis,  and  so  may 
simulate  tuberculosis.  The  bones  commonly  affected  are  the  tibia  and 
the  femur,  though  no  bone  is  exempt. 

In  Chapter  XXYI,  I  said  a  word  regarding  the  urgent  nature  of  a  case 
of  acute  osteomyelitis,  and  spoke  of  the  imperative  need  of  immediate 
treatment.  Acute  osteomyelitis,  beginning  then  in  the  diaphysis  of 
a  long  bone,  runs  riot  through  the  medullary  canal,  involving  the 
endosteum  and  then  the  cortical  bone  proper,  which  may  become 
necrotic  over  an  extensive  area.  The  periosteum  becomes  stripped  from 
the  bone,  and  the  cortex,  in  varying  degrees  necrotic,  may  lie  dormant 
as  a  sequestrum  if  the  patient  lives  to  tell  the  tale.  In  most  cases  a 
general  toxemia  of  an  extreme  type  develops,  with  exci-uciating  pain 
in  the  affected  limb,  with  a  high  fever,  and  with  other  familiar  signs  of 
septicemia.  The  patient  may  die  of  the  disease  in  a  week  or  less. 
Again,  the  inflamed  area  may  become  so  thoroughl}'  disorganized  that 
spontaneous  openings  will  develop  with  a  free  natural  drainage,  so 
that  the  constitutional  symptoms  subside,  and  the  patient  goes  on  to 
an  unsatisfactory  and  halting  recoverJ^  In  these  cases  the  sequestrum 
persists,  keeping  up  an  irritation,  and  encouraging  a  chronic  running 
sore.  If  the  reparative  processes  go  on,  they  are  brought  about  by 
the  formation  of  new  bone  through  the  activity  of  the  periosteum — 
new  bone  which  becomes  deposited  in  circular  layers — involucnmi — 
about  the  old  necrotic  shaft.  This  involucnmi  is  attached  at  either 
end  of  the  remnant  of  the  original  shaft  which  has  not  been  destroyed. 
There  results  a  walling-off  of  the  sequestmm  from  the  sound  bone  by 
a  plug  of  bone  which  in  time  becomes  dense  and  is  of  varying  width. 
As  Xichols  describes  the  condition;  "In  cases  of  spontaneous  osteo- 
myelitis, areas  of  new  endosteal  bone  may  be  irregidarly  distributed 
or  may  form  a  wall  surrounding  and  inclosing  definite  circumscribed 


THE    BOXES  947 

areas  of  purulent  inflammation,  i.  c,  there  may  be  an  abscess  with  a 
wall  of  dense  endosteal  hone."  Now  the  integrity  of  the  cortex  de- 
pen  tls  entirely  upon  the  vitality  of  the  endosteum  within  and  the  peri- 
osteum without.  "The  necrosis  and  inability  of  repair  of  the  cortical 
bone  are  the  chief  causes  of  th3  persistence  of  sequestra  and  sinuses  in 
chronic  osteomyelitis." 

The  symptoms  of  acute  osteomyelitis  are  extremely  severe,  as  a  rule, 
and  begin  with  a  sudden  localized  pain,  usually  in  the  shaft  of  a  bone. 
The  neighboring  joints  are  usually  tender  and  painful  also,  so  that  the 
patient  and  the  physician  himself  may  regard  the  case  as  one  of  "articu- 
lar rheumatism."  It  has  been  pointed  out  that  gentle  pressure  at  some 
point  over  the  shaft  at  a  distance  from  the  area  of  pain  brings  out  and 
accentuates  localized  pain  in  the  lesion.  After  the  onset  of  the  attack 
there  soon  develops  a  swelling  of  the  soft  parts  about  the  bone,  with 
redness  and  tenderness  and  acute  edema.  The  patient's  temperature 
rises  to  103°  or  104°  F.;  the  pulse  mounts,  and  the  picture  is  one  of 
an  acute  constitutional  disturbance.  The  leukocyte  count  inns  high 
—even  to  40,000. 

A  careful  surgeon  should  be  able  to  distinguish  this  disease  readily 
from  the  various  joint  infections  and  from  tuberculosis,  for  acute 
osteomyelitis  is  localized  in  the  shaft  of  the  bone  and  is  ushered  in  by 
symptoms  far  more  alarming  and  ovei-w^helming  than  is  tuberculosis  or 
other  infectious  joint  lesions. 

The  treatment  of  acute  osteomyelitis  is  not  always  easy,  and  depends 
upon  the  stage  of  the  disease.  Xichols  divides  the  course  of  the  disease 
into  four  stages:  (1)  That  of  infection,  necrosis,  suppuration,  general 
intoxication;  (2)  the  subacute  stage,  which  begins  with  the  evacua- 
tion of  pus;  (3)  the  chronic  stage,  marked  by  the  formation  of  seques- 
trum, involucrum,  and  sinuses;  (4)  the  chronic  stage  of  localized  bone 
abscesses. 

In  the  acute  stage  the  surgeon  must  cut  down  upon  the  bone,  tre- 
phine the  shaft,  and  drain  the  bone-marrow^,  frequently  through  an 
extensive  opening  through  the  cortex;  and  he  should,  if  possible,  curet, 
and  wash  out  thoroughly  all  involved  marrow,  tracing  out  and  follow- 
ing up  suspicious  areas  in  the  diaphysis  and  even  in  the  epiphysis. 

In  the  subacute  stage  there  are  a  necrotic  shaft  and  a  proliferation 
of  the  periosteum,  and  this  is  the  stage  which  is  often  the  most  difficult 
of  treatment.  In  this  connection  Nichols  urges  the  employment  of  a 
careful  routine  adapted  to  varying  conditions  of  this  subacute  stage. 
There  are  three  classes  of  conditions  which  warrant  three  definite  and 
defined  procedures:  "(1)  Removal  of  the  necrotic  sequestrum  before 
a  definite  involucrum  has  been  formed,  while  the  periosteum,  although 
proliferating,  is  still  plastic.  (2)  Removal  of  the  sequestmm  just  as  soon 
as  a  sufficient  amount  of  involucrum  has  been  formed  to  carry  on  the 
function  of  the  original  shaft.  In  the  early  stages  such  a  young  involu- 
crum has  a  limited  power  of  central  grovrth,  and  in  favorable  cases  may 
obliterate  the  cavity  left  by  the  removal  of  the  sequestrum.  (3)  Re- 
moval of  the  sequestrum  after  the  involucrum  has  become  dense  bone. 


948  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

]ii  such  cases  a  cavity  ahvays  is  left  surixniiulecl  by  dense  involucrum 
lined  with  granuhition  tissue,  and  such  a  cavity  will  persist  indefinitely 
because  the  dense  involucrum  has  no  power  of  central  growth." 

It  is  obvious  that  such  descriptions  of  osteomyelitis  and  its  treat- 
ment appear  to  confound  acute  osteomyelitis  with  chronic  osteomyelitis. 
Indeed,  chronic  osteomyelitis  develops  out  of  acute  osteomyelitis. 
Chronic  osteom^-elitis  is  the  condition  of  bone  which  is  seen  toward 
the  end  of  that  stage  which  Nichols,  somewhat  to  our  confusion,  calls 
the  second  part  of  the  subacute  stage.  In  other  words,  when  the 
disease  presents  sequestrum,  sinus  formation,  abscess  formation,  and 
the  growth  of  involucrum,  we  may  fairly  describe  the  condition  as  one 
of  chronic  ostcoryiyclitis. 

The  treatment  of  the  chronic  stage  with  dense  involucrum  and 
extensive  sequestrum  is  by  mallet  and  chisel.  We  remove  the  seques- 
trum and  give  drainage,  but  the  bone  defect  does  not  heal,  and  a  filthy 
discharging  cavity  remains  for  years.  Surgeons  have  long  sought  a 
remedy  for  this  trying  condition — a  remedy  which  shall  close  the  bone 
defects.  The  first  desideratum  for  closing  these  defects  is  thoroughly 
to  disinfect  the  bone  cavity — an  extremely  difficult  matter.  It  should 
be  undertaken,  however,  again  and  again  if  at  first  it  fails,  and  a  fairly 
successful  method  is  as  follows:  Scrape  thoroughly  and  cut  away  all 
infected  tissue,  smear  the  fresh  surface  with  strong  carbolic  acid ;  wash 
away  the  carbohc  with  a  70  per  cent,  solution  of  alcohol;  turn  in  skin- 
fiaps  so  that  they  shall  lie  snugly  along  the  bottom  of  the  cavity  and 
cover  it  completely.  If  the  preparation  of  the  bone  has  been  perfectly 
made,  these  skin-flaps  will  "take."  The  after-care  of  these  cases  must 
be  followed  in  a  most  painstaking  fashion.  The  wound  must  be  dressed 
frequently  and  must  be  kept  scrupulously  clean,  else  some  slight  point 
of  infection  may  develop  fresh  trouble,  and  undo  totally  the  new  skin- 
grafts. 

Chronic  localized  bone  abscesses  develop  variously.  They  may  be 
small  or  may  occupy  nearly  all  the  shaft  of  the  long  bone.  They  cause 
no  definite  sequestrum.  Drain  them  through  a  trephine  opening,  and 
you  will  have  left  a  dense  bony  wall.  It  is  extremely  difficult  to  close 
these  cavities.  If  they  be  rendered  aseptic,  they  may  be  filled  with 
blood-clot  which  wuU  organize,  or  they  may  be  treated  by  the  skin-flap 
method. 

Bone  tuberculosis  is  a  common  affection.  The  tubercle  bacillus  gains 
entrance  through  the  blood-8t)'eam,  usually,  to  the  bone-marrow,  where 
it  causes  the  formation  of  miliary  tubercles.  Other  secondary  tubercles 
then  arise;  caseation  results,  and  extensive  softening  of  the  bone- 
marrow  is  produced.  Then  the  bony  trabeculae  become  involved  and 
a  definite  tuberculous  abscess  cavity  is  formed. 

Bone  tuberculosis  nearly  always  begins  in  the  epiphysis  of  the  long 
bones.  The  process  extends  toward  the  neighboring  joint,  so  that  we 
commonly  find  a  joint  tuberculosis  superimposed  upon  and  masking, 
as  it  were,  a  bone  tuberculosis.  We  shall  concern  ourselves  some- 
what later  with  a  description  of  joint  tuberculosis. 


THE   BONES  949 

In  rarer  cases,  however,  the  bones  alone  are  involved — such  bones 
especially  as  the  ribs  and  the  pelvic  bones.  In  these  purely  bone  cases 
the  symptoms  are  quite  different  from  the  symptoms  of  joint  tubercu- 
losis. Bone  tuberculosis  develops  slowly ;  it  destroys  the  bone  gradually, 
forming  abscesses,  and  in  a  mild  degree  involves  the  surrounding  soft 
parts,  which  break  down  and  become  riddled  with  sinuses ;  or  the  abscess 
may  remain  latent  for  a  long  time,  giving  us  a  true  picture  known  as 
"cold  abscess." 

Bone  tuberculosis  shows  no  clear  and  definite  symptoms.  Usually 
there  is  pain,  not  very  severe;  sometimes  a  thickening  in  the  bone 
can  be  felt,  especially  in  that  form  of  tuberculosis  in  young  children 
which  is  called  tuberculous  dactylitis — a  spindle-shaped  enlargement 
of  one  of  the  phalanges.  Often,  too,  we  find  evidences  of  tuberculosis 
in  other  parts  of  the  body,  in  the  cervical  lymph-nodes  or  in  the  lungs, 
while  the  x-v&y  gives  us  a  picture  of  disorganized  bone.  The  familiar 
tuberculin  test,  either  by  injection  or  by  instillation  into  the  eye,  may 
give  us  useful  information. 

The  treatment  of  bone  tuberculosis  is  not  so  simple  a  matter  as  some 
recent  writers  have  claimed.  We  are  not  to  treat  tuberculosis  of  bone 
as  though  it  were  a  malignant  disease — that  is  to  say,  we  are  not,  under 
all  circumstances,  to  excise  the  disease  with  a  wide  margin.  Indeed, 
coincident  tuberculosis  elsewhere  may  contraindicate  such  treatment 
in  advanced  cases;  while  in  incipient  cases,  especially  in  fairly  robust 
persons,  we  are  justified  in  resorting  to  properly  conducted  -  fresh-air 
treatment.  Wholesome  living  in  a  dry  climate  without  operation  is 
more  likely  to  eradicate  bone  tuberculosis  than  is  an  operation  followed 
by  residence  in  the  city  slums. 

Syphilis  of  bone  is  both  congenital  and  acquired,  and  the  gumma  is 
its  most  important  manifestation.  Gumma  develops  in  the  periosteum 
or  in  the  medulla,  or  it  may  extend  to  the  bone  from  a  neighboring  tis- 
sue. The  gumma  is  a  lesion  of  late  syphilis,  as  a  rule;  and  whether 
the  syphilis  be  inherited  or  acquired,  its  processes  are  similar  and 
characteristic  and  its  treatment  does  not  vary.  Two  processes  go  hand 
in  hand  as  the  gumma  progresses — destruction  and  construction. 
The  granulation  tissue  of  the  g-umm.a  infiltrates  the  bones,  causing 
necrosis;  at  the  same  time  the  surrounding  tissue  is  stimulated  to 
produce  bone.  For  these  reasons  the  surface  of  the  diseased  bone 
appears  irregular,  roughened,  and  eroded,  while  the  bone  as  a  whole 
may  be  larger  than  normal.  If  the  entire  bone  is  involved,  it  may 
become  hardened  and  thickened  (eburnation) ;  or  as  the  result  of  exces- 
sive lacunar  absorption  the  bone  may  become  thin  and  frail,  so  that 
it  is  easily  fractured.  In  both  forms  periostitis  frequently  develops 
early,  and  often  simultaneously,  in  different  bones — upon  the  frontal 
and  the  parietal  bones,  the  tibia,  the  sternum,  and  the  clavicle.  This 
form  of  periostitis  appears  as  a  flat  elastic  nodule  covered  by  normal 
skin,  which  may  become  red  and  edematous  as  the  nodule  enlarges. 
During  the  later  stages  of  syphilis  a  gummatous  process  in  the  peri- 
osteum develops  slowly — on  the  inner  layer  of  the  periosteum,  from 


950  MINOR    SURGERY — DISEASES    OF    STRICTURE 

which  it  penetrates  the  bone.  In  these  ciuse.s  the  nodules  are  fiat, 
circumscribed,  little  painful,  and  found  in  nuich  the  same  places  as  in 
early  periostitis. 

(iunnnatous  osteitis  may  acconi})any  j)eriostitis  or  be  secondary 
to  it.  It  occurs  in  the  hard  palate  and  the  nasal  and  facial  bones;  it 
perforates  and  destroys  them.  We  recognize  such  a  patient,  in  the  one 
case,  by  his  articulation,  in  the  other  by  his  characteristic  saddle-nose. 

Gummatous  osteomyelitis  is  more  rare.  Gelatinous  foci  as  big  as 
a  pea  or  a  nut  develop  in  the  bone-marrow  and  in  the  medullary  spaces. 
Sometimes  these  foci  cause  no  pain,  or  again  the  pain  may  be  excruciat- 
ing. The  foci  infiltrate  the  bones;  they  are  multiple;  gradually  they 
liquefy,  while  the  surrounding  bone  becomes  thickened  and  sclerotic. 
A  syphilitic  secjuestrum  forms  and  separates  slowly,  and  may  lie  bare  at 
the  bottom  of  the  open  wound  for  3-ears  without  becoming  tletached 
from  the  surrounding  involucrum.  We  see  this  condition  especially 
in  the  frontal  and  parietal  bones.  The  gaping,  filthy  sores  of  the 
victim  are  familiar  in  European  clinics,  but  are  less  common  in  this 
country. 

Syphilitic  dactylitis  resembles  outwartlly  tuberculous  dact^ditis. 
It  is  a  congenital  disease.  A  gumma  develops  within  the  short  finger- 
bones,  which  become  expanded  and  thickened.  Ulcers  and  fistulse  may 
result,  and  the  entire  phalanx  may  become  extruded,  or  absorbed  with- 
out an  accompan}'ing  suppuration. 

There  are  diffuse  forms  of  syphilitic  periostitis  and  gummatous 
osteomyelitis.  These  forms  run  their  course  with  suppuration,  and 
there  may  be  extensive  destruction  of  the  bones  of  the  skull,  of  the 
forearm,  and  of  the  leg.  The  affected  bones  become  thickened  and 
heavy,  or  they  niay  become  brittle  and  light.  If  this  diffuse  form  of 
bone  syphilis  occurs  in  early  childhood,  a  curiously  characteristic 
deformity  develops,  especially  in  the  bones  of  the  leg.  The  tibia 
becomes  elongated,  curved  fonvard,  and  thickened,  and  a  prominence 
develops  upon  its  anterior  surface  in  contrast  to  the  straight  line  of  the 
other  leg. 

Such  and  such-like  are  some  of  the  more  common  syphilitic  affec- 
tions of  the  bones.  The  diagnosis  of  syphilis  is  usually  easy  when  the 
disease  is  well  advanced,  but  is  correspondingly  difficult  in  its  early 
stages,  for  so-called  gouty  deposits  and  tuberculous  abscesses  attached 
to  the  bones  may  resemble  closely  these  gummatous  lesions.  Usually 
we  must  make  our  diagnosis  b}'  careful  study  of  the  history  of  the  case, 
and  often  by  exclusion  and  through  the  use  of  antisyphilitic  remedies. 
It  does  not  suffice  to  treat  these  cases  with  medicine  merely.  The  good 
results  of  medicine  may  be  extremely  slow,  but  we  may  sometimes 
hasten  recovery  by  judicious  surgical  measures — by  laying  bare  the 
diseased  bone,  by  removing  sequestra,  by  cureting  gummata,  and  by 
draining  abscesses.  It  is  with  bone  gummata  as  with  those  intra- 
cranial gummata  of  which  I  have  written — medicine  alone  may  cure 
in  time,  but  during  the  time  the  patient  may  die  from  the  coincident 
effects  of  the  local  ailment. 


THI<:    BONES  951 

Rickets  or  rachitis  is  a  peculiar  disease  of  the  bones  of  children. 
Perhaps  it  is  congenital — we  cannot  regard  it  as  parasitical — and  it  is 
characterized  by  nutritional  disturbances  and  striking  structural  irreg- 
ularities. The  most  marked  pathologic  feature  of  rickets  seems  to 
be  a  deficiency  of  the  calcium  constituents  of  the  bones,  so  that  the 
bones,  being  soft,  are  made,  through  muscular  and  weight-bearing 
action,  to  assume  peculiar  relations  and  forms.  The  familiar  rachitic 
lesion  is  constantly  seen  along  the  line  of  junction  between  bones  and 
cartilages,  especially  in  the  chest,  where,  owing  to  the  activity  of  growth 
of  the  cartilage  and  the  slow  formation  of  the  bone,  there  result  apparent 
bony  prolongations  into  the  cartilaginous  tissue.  When  examining 
such  a  chest  one  feels  rows  of  small,  irregular  nodules  lying  by  the  side 
of  the  sternum — ''rosary."  There  appears  to  be  an  obscure  but  appar- 
ently undoubted  relationship  betw^een  rachitis  and  status  lymphaticus. 

Rachitis  results  in  certain  marked  skeletal  changes — a  thickening 
of  the  shafts  of  the  long  bones,  the  flat  bones,  and  of  epiphyseal  extremi- 
ties, with  a  frequent  stunting  of  bony  development,  so  that  the  bones  do 
not  attain  their  normal  length.  The  periosteum  frequently  becomes 
warped  and  curved ;  and  this  curving  adds  to  the  singular  irregularity 
of  the  bone  structure.  In  extreme  cases  the  bones  are  so  soft  that  they 
bend  readily,  when  the  child  may  develop  an  extraordinary  degree  of 
bowlegs  or  bow-arms,  flat  feet,  club-feet,  and  clubbing  of  the  finger- 
tips, while  the  fontanel  of  the  skull  may  remain  open  unduly  long. 
The  bones  of  the  face  also  are  soft  and  undeveloped  in  rickets;  the 
face  appears  absurdly  small;  dentition  is  delayed,  and  erupted  teeth 
decay  early. 

Changes  other  than  those  of  the  bones  occur  in  rachitis :  There  may 
be  hydrocephalus,  spina  bifida,  enlargement  of  the  liver  and  spleen; 
while  the  child  is  sickly,  fretful,  irritable,  dull,  sweats  easily,  and  stands 
with  heavy,  nodding  head  and  protuberant  belly. 

Rachitis  is  always  discussed,  however  briefly,  in  text-books  of 
general  surgery,  and  I  have  followed  convention,  but  I  doubt  if  rachitis 
properly  can  be  regarded  as  within  the  field  of  the  general  surgeon; 
at  any  rate,  its  treatment  usually  is  medical;  that  is  to  say,  its  treatment 
consists  in  abundant  feeding  of  the  child,  especially  with  fattening 
foods;  in  the  use  of  hypophosphites,  and  sometimes  phosphorus;  more- 
over, we  are  beginning  to  believe  in  the  employment  of  extracts  of  the 
thyroid  and  pituitary  bodies. 

The  orthopedic  surgeon,  however,  finds  occasion  to  treat  rachitic 
children.  Up  to  the  age  of  three  years  mechanical  treatment  is  of 
little  value.  When  the  child  is  three  years  old,  however,  the  orthopedic 
surgeon  may  employ  the  familiar  leg  brace  to  straighten  bowlegs 
and  knock-knees.  In  the  case  of  an  older  child  we  operate  for 
mild  forms  of  bowlegs  and  knock-knees  by  osteoclasis,  which  consists 
in  the  fracture  of  the  bone  by  means  of  an  osteoclast.  In  the  case  of 
an  adult  we  perform  osteotomy — and  a  linear  osteotomy  is  preferred  by 
orthopedic  surgeons  to  a  removal  of  a  wedge  of  bone,  which  shortens 
the  leg. 


952 


MINOR   SURGERY — DISEASES    OF   STRUCTURE 


Other  operations  on  the  bones  occasionally  may  be  undertaken,  but 
it  is  upon  the  leg  bones  especially  that  the  orthopedic  surgeon  will  be 
inclined  to  exercise  his  ingenuity.  After  these  fracturing  operations 
the  limb  must  be  dressed  in  a  plaster  splint  and  treated  as  a  fracture, 
although  in  most  cases  the  time  of  convalescence  will  be  shorter  than 
is  the  case  with  ordinary  traumatic  fractures  of  these  bones. 

There  are  various  other  diseases  of  bone  with  which  the  pathologists 
and  at  times  the  surgeons  must  deal.     There  is  osteogenesis  imperfecta 
— a  congenital  disease  characterized  by  fragility  of  the  bones,  with  result- 
ing fractures — a  disease  due  to  the  lack  of 
formative  power  in  the  bony  tissues. 

There  is  chondrodystrophia  foe  talis,  an- 
other rare  congenital  disease,  described  by 
Miiller  in  ISGO.  He  tlistingiiished  it  from 
cretinism  and  from  rickets,  and  showed 
that  the  failure  of  the  long  bones  to  de- 
velop is  due  to  a  disturbance  of  the  zone  of 
proliferating  cartilage  at  the  epiphyseal 
line.  The  disease  is  frec^uently  mistaken 
for  rickets,  and  doubtless  is  that  condi- 
tion which  has  received  the  name  ''fetal 
rickets." 

There  is  fragilitas  ossium  (osteopsath- 
yrosis). This  is  a  condition  not  uncom- 
mon. It  is  not  a  definite  disease,  but  ex- 
presses rather  a  clinical  condition,  and 
there  are  various  causes  which  bring  about 
a  s}-mptomatic  fragility  of  bones.  Old  per- 
sons especial!}^,  as  we  have  seen,  are  the 
subjects  of  fragile  bones,  and  the  cut  illus- 
trates well  this  extraordinary'  condition. 

There  is  leontiasis  ossium,  a  disease  of 
the  skull  bones,  in  which  new-grovrths  or 
hyperostoses  develop,  diffuse  and  tumor- 
like. Sometimes  these  hyperostoses  cause 
an  enormous  enlargement  of  the  skull :  the 
new  bone  may  extend  over  the  whole  face, 
as  well  as  over  the  vault.  The  normal 
skull  openings  may  become  closed,  so  that 
the  cranial  nerves  are  obliterated  and  the 
orbits  are  covered. 

Obviousl}-,  such  diseases  as  osteogenesis 

imperfecta,     chondro-dystrophia     fetalis. 

fragilitas  ossium,  and  leontiasis  ossium  are 

little  susceptible  to  treatment. 

Osteomalacia  is  a  disease  characterized  by  a  softening  of  the  bones 

and  by  other  changes  which  suggest  rickets.     Unlike  rickets,  however, 

osteomalacia  is  a  disease  of  adults.     Curiously  enough,  77)en  seldom  are 


Fig.  654. — Fragilitas  os- 
sium (Warren  Museum,  Har- 
vard Medical  School  i.  Skel- 
eton of  an  adult  Indian.  Prob- 
ably adult  osteogenesis  imper- 
fecta (Nichols,  in  Keen's  Sur- 
gery). 


Tin:  BONES  953 

subjects  of  osteomalacia,  although  the  disease  is  not  uncommon  in 
women.  It  is  not  hereditary,  and  it  may  develop  in  persons  previously 
robust.  We  know  not  its  etiology,  although  writers  talk  of  cold,  wet, 
malnutrition,  and  starvation.  Nichols  suggests  that  osteomalacia  may 
be  a  result  of  some  complicated  organic  secretion— some  internal  glandu- 
lar secretion,  the  bones  becoming  friable,  soft,  and  fragile,  the  cortex 
thin,  and  the  periosteum  thickened.  Such  bones  may  easily  be  cut. 
The  disease  has  been  most  obvious  especially  at  the  woman's  time  of 
puerperium,  when  the  bones  of  the  spine,  the  thorax,  the  shoulder, 
and  the  limbs  are  affected.  Moreover,  the  disease  begins  irregularly 
to  progress,  being  more  active  during  pregnancies.  Sometimes  the 
process  ceases  and  the  woman  recovers ;  again  the  patient  may  live  for 
a  number  of  years  and  then  die  of  the  disease. 

Osteomalacia  at  first  is  characterized  by  a  dull  pain  in  the  bones. 
Pregnant  women  have  pain  in  the  pelvis.  Then  there  are  muscle 
cramps  and  contractions.  Patients  assume  characteristic  bending 
positions  in  order  to  relieve  the  pain  through  the  pelvis  and  legs.  These 
patients  do  not  lose  flesh,  their  appetites  are  good,  and  their  nutritional 
functions  are  not  disturbed  for  a  time.  Later,  extreme  deformities 
develop— bowlegs  and  flat  feet— and  fractures  occur.  Gradually  these 
recurring  misfortunes  wear  out  the  victim,  and  if  the  case  be  steadily 
progressive,  she  dies  of  exhaustion. 

We  can  help  these  persons  often  by  treatment,  especially  if  we  see 
the  cases  early.  We  must  institute  careful  dieting,  and  a  life  free  from 
activities  and  cares,  so  far  as  possible.  Women  should  avoid  pregnan- 
cies, and  in  other  rational  and  common-sense  ways  attempt  to  maintain 
their  general  health.  No  drugs  are  of  service.  Some  enthusiastic 
surgeons  have  thought  to  benefit  the  patients  by  ovariotomy.  They 
do  not  benefit  them,  so  far  as  now  appears.  Our  suggestions  for  treat- 
ment are  the  stereotyped,  commonplace,  and  conventional  suggestions. 
Unfortunately,  however,  most  of  the  patients  are  among  the  poor  and 
laboring  classes.  They  cannot  be  put  in  the  w^ay  of  life  most  beneficial 
to  their  condition.  They  go  on  gradually  to  invalidism  and  to  prema- 
ture death. 

Osteitis  deformans  is  a  chronic  disease  of  the  bones  which  results 
in  their  deformity.  The  disease  is  not  particularly  uncommon,  as  we 
are  learning  through  recent  researches,  especially  those  of  Locke.  Sir 
James  Paget  described  osteitis  deformans  in  1877,  and  the  disease  is 
sometimes  called  by  his  name.  It  is  an  ailment  of  advanced  years,  and 
may  affect  one  or  several  bones,  especially  the  bones  of  the  legs.  It  is 
progressive,  and  it  leads  ultimately  to  extreme  deformities.  The  x-ray 
helps  us  in  the  diagnosis,  for  without  the  x-ray  osteitis  deformans  m 
its  early  stages  might  well  be  mistaken  for  several  other  diseases— 
for  acromegaly  especially. 

Osteitis  deformans  should  not  be  mistaken  for  arthritis  deformans, 
which  is  a  disease  confined  to  the  joints,  whereas  the  disease  we  are 
considering  is  confined  to  the  bone-shafts  themselves. 

We  know  not  the  cause  of  osteitis  deformans.     Paget  and  von 


954  MINOR  sunG?:RY — diseases  of  structure 

Kccklinghauscn  held  various  theories  which  need  not  disturb  us,  while 
Park  suggests  phiusibly  that  two  or  three  different  t}'pes  of  bone  changes 
are  coincidentaliy  present — trophoneurotic  atrophy  and  irritative  hyper- 
trophy side  b}'  side.  At  any  rate,  the  changes  in  the  bone  are  a  com- 
bination of  absorption  and  atrophy.  New  bone  forms  over  the  skull 
and  new  bone  develops  along  the  shafts  of  the  long  bones,  especially 
of  the  legs,  so  that  the  legs  become  bowed  and  are  strikingly  unsym- 
metric. 

The  disease  is  insidious,  tedious,  deforming,  long  continued,  painful. 
The  legs  become  stiff  and  weak.  The  patient  walks  wdth  a  character- 
istic waddling  gait.  Spontaneous  fractures  may  occur.  Treatment 
is  largely  palliative.  If  the  surgeon  is  consulted  by  one  of  these  patients, 
however,  he  must  do  something,  and  he  may  be  able  to  do  a  great  deal 
to  relieve  the  most  distressing  symptoms,  though  he  may  not  cure  the 
disease.  Most  of  these  patients  are  in  wretched  condition;  they  must 
be  fed  up,  given  an  out-of-doors  life,  and  provided  with  cod-liver  oil, 
arsenic,  and  massage.  Some  physicians  feel  that  potassium  iodid 
helps  these  cases.  I  have  seen  no  benefit  from  it.  One  must  attempt 
to  relieve  the  pain.  Such  counterirritants  as  the  actual  cauter}-  are 
extremely  useful  at  times  for  this  purpose. 

Like  so  many  other  chronic  bone  diseases,  however,  osteitis  defor- 
mans is  a  melancholy  ailment,  depressing  to  the  patient,  little  stimulat- 
ing to  the  surgeon,  save  to  the  most  optimistic. 

Acromegaly  has  been  but  recently  described,  for  acromegaly  for- 
merly was  confused  with  osteitis  deformans,  with  syphilis  of  bone,  and 
with  various  other  chronic  diseases  of  the  bone.  Acromegaly  causes 
enlargements  of  the  bones — enlargements  especially  at  the  extremities 
of  the  body,  the  brows,  the  chin,  the  fingers,  and  the  toes.  Acromegaly 
involves  other  tissues  also  in  its  career — the  hands  become  large  and 
coarse;  the  features  lose  their  familiar  outlines  and  become  heavy  and 
dull;  the  eyelids  become  thickened;  the  nose  becomes  flattened;  and 
finally  even  the  larynx,  the  large  vessels,  and  the  heart  become  affected. 

Properly,  care  of  the  disease  falls  to  the  internist  or  the  general  prac- 
titioner. The  surgeon  can  do  little  for  it  beyond  an  occasional  tenotomy 
or  some  other  palliative  operation;  and  the  internist  even  draws  little 
encouragement  from  his  measures. 

It  appears  to  be  accepted  that  the  disease  is  due  to  some  kind  of 
change  in  the  pituitary  body,  or  to  a  hypertrophy  or  a  tumor  of  that 
organ.  Drugs  are  of  no  benefit.  Writers  especially  interested  in  the 
matter  are  advising  us  to  experiment  with  the  extracts  of  various  glands 
— the  thyroid,  the  ovary,  the  adrenals. 

One  sees,  then,  that  we  are  without  definite  final  knowledge  regard- 
ing this  remarkable  disease,  and  that,  through  experimentation,  we 
must  endeavor  to  arrive  at  a  clear  conception  of  its  nature  and  of  its 
treatment. 


THE   JOINTS  ^^ 


THE   JOINTS 


The  joints  are  structures  of  more  varied  and  constant  suigical 
interest  than  are  the  bones,  for  the  joints  are  extremly  complex  m  the.r 
nX  up   and  an  injury  or  a  disease  of  a  joint  comprehends^lesions  far 
more    omphcated  than  are  the  correspondmg  lesions  of  a  bone.     Fo 
Zse  m"sons  joint  lesions  are  often  more  difficult  of  diagnosis,  and  far 
moeScult  of  treatment  than  are  bone  lesions.    When  we  study 
Znl  lesions  we  have  to  consider  damage  to  synovial  membranes,  to 
ola'es  to  ligaments,  to  bones,  tp  tendons,  to  muscles,  to  bursa.,  and 
Onetimes  to  nerves  and  blood-vessels-for  all  these  structures  enter 
hZTiS  into  the  composition  of  a  joint,  or  are  closely  associated  with 
it  Ta  certain  sense,  joints  and  joint  cavities  are  similar  to  such  grea 
serous  cavities  as  the  peritoneal  pouch  or  the  pleural  cavity,     lor 
hiH-LsSn  joint  infections  may  be  highly  f-^-"-' -tpZ^r'^h: 
and  inflammations  far  more  significant  than  at  first  appears      Ihe 
rectus  femoris  muscle  may  be  extensively  torn  and  befouled,  but  with 
"iSnabScare  the  patient  quickly  will  recover;  -^-- ^^e  -^^^^"'^ 
ing  knee-joint,  when  punctured  by  a  delicate  f««dle   may  receive  an 
infection  which  will  lead  to  septicemia  with  the  loss  of  imb  or  life 

We  divide  joint  lesions  into  familiar  classes:  into  mjuries  and  dis- 
eases and  theL  two  classes  are  subdivided  into  such  injuries  as  con- 
tusions sprains,  and  dislocations,  with  their  various  trams  of  sequete; 
hlethediseas'esof  joints  partake  of  the  nature  of  d-- processes^n 
the  surrounding  structures,  and  are  mamly  inflammations,  either  acute 
or  chronic     We  must  now  take  up  consecutively  the  various  joint  ail- 

"Tcontusion  of  a  joint  is  ^-sed  by  violence,  and  results  in  varying 
deio-ees  of  damage  to  the  parts  which  enter  into  the  joint.     It  s  a  sub 
ruSneous  iniurv      The  synovial  membrane  may  be  braised,  the  hga- 
mertom  and  the  soft  parts  lacerated.     Immediately  there  results  an 
rtoourrg  of  fluid  into  the  synovial  sac,  which  effusion  causes  the  join 
?o  sweU     The  fluid  may  be  ciar  seram;  it  may  contam  flakes  or  masses 
o^  fib?^' ;  oJ ft  may  be  bLdy ;  and  the  greater  the  quantity  of  blood,  the 
greater  he  amount  of  fibrin  and  clots  collected  m  the  l"-  ^^'.^av  t 
the  same  time  the  intrinsic  cartilages  concerned  with  the  jomt  may 

without  pain.     If  such  a  joint  be  left  to  itself,  '"  t™^'''^i    ^^„,^  ^-iU 

person,  the  damage  will  f  ^P-^™  -^^'  ,tc  veo-hr^sues 
be  long— in  marked  contrast  to  the  prompt  lecuve  y 
upon  intelligent  and  careful  treatment.         ..^     .     •     ,i:,,pp+  ^piotion 
Treatment -The  care  of  one  of  these  jomts  is  m  ^Inect  relation 
to  ZTToi  the  healing  process.     The  initial  swellmg,  effusion,  and 


956  MINOR    SURGERY — DISEASES    OF    STRUCTURE 

inflammation  must  be  met  by  absolute  rest.  As  soon  as  reaction  has 
be^un,  however,  and  the  absorbent  processes  are  at  woik.  measures 
which  siiiill  stimuhite  absorption  are  of  the  greatest  \uku'.  I  have 
already  discussed  these  matters  when  considering  the  massage  of  dis- 
locations. Our  routine  treatment,  then,  in  the  case  of  a  contused  joint 
is  to  immobilize  it  absolutely  in  splints  for  two  oi-  three  days;  then,  while 
keeping  the  patient  quiet,  daily  to  employ  massage  or  dry  baking,  or 
both,  gradually  lengthening  the  time  of  the  massage  and  varying  it  with 
passive  and  active  movements  until  function  is  restored.  'J'he  time  of 
convalescence  for  a  joint  so  treated  will  vary  for  from  a  week  to  three 
months. 

We  talk  about  sprains,  but  who  may  define  "sprain,"  or  explain  its 
distinction  from  a  contusion?  Good  writers  have  said  that  a  sprain  is 
"an  injury  in  which  there  is  a  sudden  momentary  displacement  of 
the  bones  entering  into  a  joint,  the  parts  returning  immediately  to  their 
normal  relations."  ^  Numerous  other  writers  define  sprains  in  cumber- 
some, bev/ildering,  or  enlightening  paragraphs.  In  fact,  a  spi-ain  may 
be  regarded  as  a  mild  form  of  contusion.  The  parts  about  the  joint 
swell  more  or  less;  fluid  may  be  poured  out  into  the  synovial  sac; 
ligaments  may  be  slightly  torn  even,  but  one  of  the  most  constant  and 
most  interesting  features  of  the  ordinary  mild  sprain  is  the  damage  to 
tendons  and  tendon-sheaths,  which  is  evidenced  at  once  by  an  acute 
tenosynovitis.  In  the  case  of  a  sprained  ankle  especially  our  onl}^ 
evidence  of  sprain  sometimes  will  be  the  fulness  or  swelling  about  the 
tendons  below  the  malleoli  and  along  the  dorsum  of  the  foot. 

We  have,  in  Chapter  XXVI.  already  discussed  sprains  and  their 
treatment,  nor  need  we  here  rehearse  the  discussion  of  dislocations, 
which  the  reader  will  find  in  Chapter  XXIX. 

"  Acute  synovitis  "  is  the  term  given  to  that  form  of  active  inflam- 
matory exudation  into  a  joint — a  non-infective  inflammation,  some- 
times, if  you  choose — which  I  have  described  in  the  preceding  para- 
graphs. 

Suppurative  inflammation  of  the  joints  is  a  matter  far  more  serious 
than  contusion,  sprain,  or  dislocation.  These  inflammations  are  the 
result  of  infections,  and  are  often  due  to  damage  from  without,  from 
missiles  or  weapons,  or  they  may  be  associated  with  compound  frac- 
tures of  bones.  Pyogenic  organisms  enter  into  the  joint  and  an  acute 
purulent  inflammation  is  produced.  Then  the  joint-cavity  rapidly  is 
filled  with  pus  or  a  purulent  fluid,  the  synovial  membrane  becomes 
injected,  dark,  or  purplish-red  in  color,  and  thickened,  often  extremely 
thickened,  while  the  joint-cavity  may  become  enormously  distended. 
The  ligaments  become  softened  and  disorganized,  the  bone  epiphyses 
become  eroded  and  necrotic,  while  the  infection,  passing  beyond  the 
joint,  produces  most  grave  constitutional  disturbances. 

This  last  fact- — constitutional  disturbance — leads  us  to  a  further 
important  consideration  regarding  the  etiology  of  joint  suppurations. 
I  have  spoken  of  their  origin  from  traumatism,  but  the}'  may  arise 
1  Lexer-Bevan,  General  Surgery,  1908. 


TlliO   .JOINTS  957 

from  a  great  variety  of  general  systeniic  diseases,  from  pyemia,  from 
gonorrhea,  from  cerebrospinal  meningitis,  diphthei'ia,  dysentery, 
erysipelas,  glanders,  measles,  pneumonia,  and  many  other  bacterial 
infections.  As  Lovett  says,^  (quoting  Poynton :  "  It  is  no  easy  task 
to  grapple  with  the  subject  of  arthritis,  .  .  .  for  around  gout,  rheu- 
matism, and  rheumatoid  arthritis  theory  has  cast  her  bright  and 
attractive  mantle,  beneath  which  gray  and  sober  fact  is  liable  to  be 
stifled." 

If  a  suppurating  joint  remain  untreated,  disastrous  results  generally 
follow.  The  best  we  can  hope  for  is  a  gradual  subsidence  of  the  acute 
process  and  the  establishment  of  a  chronic  condition — thickening  of 
all  the  parts  of  the  joint,  adhesions,  and  a  considerable  or  complete 
limitation  of  motion,  with  marked  muscle  atrophy,  while  at  the  worst 
we  anticipate  death  from  septicemia. 

Treatment,  and  proper  treatment,  is,  therefore,  imperative.  Proper 
treatment  consists  in  draining  the  joint  at  the  earliest  possible  moment. 
Take  an  infected  knee-joint,  for  example:  The  surgeon  may  operate 
by  making  openings  at  the  side  of  the  patella  and  in  the  popliteal  space 
by  washing  out  the  joint  with  salt  solution,  and  by  inserting  rubber 
drainage-tubes  for  the  shortest  possible  distance  into  the  joint  con- 
sistent with  adequate  drainage.  In  graver  cases  the  surgeon  may  find 
it  necessary  to  lay  the  joint  widely  open  by  an  anterior  transverse  cut, 
and  to  search  out  its  depths,  to  remove  all  diseased  tissue,  and  to 
excise  the  bone-ends  even.  After  such  a  formidable  operation  he  must 
look  for  nothing  better  than  healing  with  complete  ankylosis.  Some 
desperate  cases  have  been  saved  by  a  high  amputation  as  a  last  resort. 

Chronic  arthritis  is  a  term  which  covers  a  multitude  of  thoughts 
and  a  great  variety  of  conditions.  Surgeons  and  pathologists  for  years 
have  been  discussing  the  nature  of  chronic  arthritis,  and  at  last,  in 
some  fashion,  have  developed  a  classification  which  is  rendering  chronic 
arthritis  reasonably  intelligible.  A  number  of  different  terms  have 
been  used  in  the  discussion  of  chronic  arthritis.  Let  us  rehearse  these 
terms,  that  we  may  be  sure  of  the  ^Tound  on  which  we  stand :  Rheuma- 
toid arthritis;  rheumatic  gout;  osteo-arthritis;  dry  arthritis;  chronic  rheu- 
matic arthy'itis;  'proliferating  arthritis;  chronic  rheumatism;  arthritis 
deformans,  etc. 

While  pathologists  and  surgeons  debate,  it  will  be  useful  for  us  in 
this  reading  to  adopt  the  definite  clinical  classification  of  Goldthwait  ■? 
(1)  Villous  arthritis;  (2)  infectious  arthritis;  (3)  atrophic  arthritis;  (4) 
hypertrophic  arthritis;  (5)  chronic  gout. 

A  few  words  of  definition:  Villous  arthritis  is  marked  by  a  chronic 
overgrowth  of  the  synovial  membrane;  masses  and  tags  project  into  the 
joint — tags  composed  of  granulation  tissue  or  of  cartilage  or  of  bone. 
Observe  that  these  tags  may  be  pinched  off  and  may  become  loose  in 

^  R.  W.  Lovett,  Remarks  on  the  Infection  of  Joints,  Boston  Med.  and  Surg. 
Journal,  May  24,  1906. 

2  J.  E.  Goldthwait,  Differential  Diagnosis  and  Treatment  of  the  So-called  Rheu- 
matoid Diseases,  Boston  Med.  and  Surg.  Journal,  November  17,  1904. 


958  MINOR   SURGERY — DISEASES   OF    STRUCTURE 

the  joint,  when  they  form  that  type  of  so-called  "forei^i  body"  known 
as  "joint-mouse." 

By  infectious  arthrititi  we  mean  a  lar^e  group  of  chronic  joint  affec- 
tions, often  periarticular,  which  are  thought  to  be  caused  by  impair- 
ments of  nutrition,  associated  with  micro-organisms  in  the  joint,  which 
ma}'  become  greatly  distended  with  fluid. 

Atrophic  arthritis  constitutes  a  rarer  type,  seen  in  the  cases  of 
debilitated  patients,  and  characterized  by  a  progressive  ati-ophy  of  the 
joint  structures — both  cartilages  and  bones — and  their  erosion.  These 
are  the  cases  commonly  classed  as  rheumatoid  arthritis. 

The  hypertrophic,  or  formative,  type  of  arthritis  develops  on  quite 
another  plan  from  the  atrophic  type.  In  the  hypertrophic  type  there 
are  ulcerations  of  cartilage,  but  there  is  always  a  striking  development 
of  new  bone  about  the  margin  of  the  joint  and  beneath  the  ulcerated 
cartilage.  The  new  bone  at  the  edge  of  the  joint  arises  from  the  peri- 
osteum, while  the  new  bone  beneath  the  cartilage  arises  from  the 
thickened  endosteum.  This  hypertrophic  arthritis  is  the  common 
chronic  rheumatism  of  old  people,  and  we  see  it  seated  especially  in  the 
fingers,  the  hip,  and  the  spine,  wath  resulting  deformities  (arthritis 
deformans).  These  changes  often  lead  to  the  characteristic  distorted 
fingers  of  old  age,  and  to  the  clinical  appearances  known  as  "Heber- 
den's  nodes." 

Chronic  gout  calls  for  no  consideration  here. 

Symptoms. — All  these  forms  of  chronic  arthritis  are  non-suppurative. 
They  are  progressive,  and  are  associated  with  pain,  swelling,  loss  of 
function,  stiffness,  and  deformity.  One  joint  alone  or  many  joints 
may  be  involved.  When  the  hands  and  feet  are  affected,  the  disease 
is  usually  polyarticular.  The  knee  is  the  one  complicated  joint  which 
may  be  involved  alone.  Moreover,  the  symptoms  of  chronic  arthritis 
vary,  and  yet  in  all  the  different  forms  they  are  not  dissimilar.  The 
attack  may  be  acute  and  may  be  mistaken  for  acute  "articular  rheu- 
matism," or  the  attack  may  begin  gradualh' — the  most  common  con- 
dition. 

In  these  latter  insidious  cases  the  joint  becomes  irritable  and  painful 
when  used;  it  becomes  a  little  stiff  after  being  rested;  it  may  creak,  and 
some  thickening  about  superficial  joints  may  be  detected.  The  patient 
may  complain  of  numbness  in  the  joint,  and  may  notice  a  reddening 
of  the  skin  and  sensations  of  dryness  and  burning  in  the  joint.  At 
times  the  general  health  may  suffer  from  the  outset  of  the  disease, 
and  there  may  be  slight  fever,  a  rapid  pulse,  and  loss  of  appetite.  There 
are  usually  remissions,  so  that  the  patient  speaks  of  having  attacks  of 
rheumatism.  While  there  is  joint  stiffness,  at  first  due  to  muscular 
irritation,  there  follows  in  the  later  stages  stiffness  due  to  actual  joint 
changes — to  effusion,  to  a  diffuse  and  pulpy  swelling,  and  later  to  a 
fusiform  swelling,  which  involves  synovial  membrane,  capsule  ligaments, 
and  bone.  Then  there  may  occur  distortion,  either  from  muscular  con- 
traction or  from  actual  changes  in  the  bone  ends. 

"Chronic   rheumatism"    (arthritis)    is  not  necessarily   confined   to 


THE    JOINTS  959 

adults.  Children  have  it  in  that  form  spoken  of  as  "Still's  disease," 
in  which  many  joints  are  involved,  v^ith  much  joint  thickening,  and 
with  enlargement  of  the  lymph-nodes  and  the  spleen.  In  nearly  all 
cases  the  r-ra}^  shows  characteristic  joint  changes — marginal  deposits 
of  bone  and  a  narrowing  of  the  spaces  occupied  by  the  joint  cartilages. 

Thus  we  see  that  the  disease  is  not  always  easily  to  be  distinguished 
from  tuberculosis.  In  doubtful  cases  the  surgeon  may  use  for  diagnosis 
injections  of  tuberculin,  or  may  aspirate  the  joint  and  practice  inocula- 
tion experiments. 

The  course  of  a  chronic  arthritis  is  usually  steadily  and  unfavorably 
progressive,  though  sometimes  the  disease  may  be  checked,  even  if  it 
cannot  be  cured.     The  rare  cures  are  seen  generally  in  children. 

We  undertake  treatment  of  chronic  arthritis  with  the  understanding 
that  the  disease  is  something  more  than  a  local  infection:  (1)  We  must 
increase  the  patient's  resisting  powers  by  improving  his  general  condi- 
tion; (2)  we  must  stimulate  elimination  by  the  intestines,  the  kidneys, 
and  the  skin;  (3)  we  must  improve  the  local  circulation  and  protect 
the  joint  against  injury. 

A  few  words  in  regard  to  the  treatment^  of  special  type«!  of  chronic 
arthritis : 

Chronic  villous  arthritis  calls  for  the  usual  general  treatment,  while 
at  the  same  time  the  surgeon  should  not  neglect  the  special  conditions 
present.  Hot-air  baking,  w^ith  temperature  well  above  200°  F.,  should 
be  employed,  together  with  supporting  bandages  and  splints  if  neces- 
sary. If  the  villi  persist,  the  surgeon  is  justified  in  opening  the  joint 
and  removing  them.  The  joint  fringes  and  loose  bodies  being  removed 
by  this  operation,  a  marked  improvement  in  the  patient's  condition 
may  follow. 

Infectious  arthritis  may  start  in  with  severe  symptoms,  but  in  this 
type,  even  more  than  in  the  others,  active  hyperemia  treatment  by 
baking  is  often  of  surprising  value,  while  in  certain  cases  Bier's  passive 
hj'peremia  is  of  advantage.  We  must  not  keep  these  joints  fixed  too 
long,  although  fixation  is  needed  to  relieve  pain ;  but  we  should  supple- 
ment our  other  treatment  by  frequent  massage  and  by  passive  move- 
ments— under  an  anesthetic  if  necessary.  If  there  be  obstinate  con- 
tractures, we  should  do  tenotomy,  or  break  up  the  contractures  perhaps 
by  forcible  extension  with  the  patient  under  an  anesthetic. 

Atrophic  arthritis  is  extremely  obstinate,  and  may  be  helped  bj'  resi- 
dence in  a  hot  climate  only.  Further,  we  must  persistenth'  employ 
massage  (Zander)  and  passive  movements.  Moreover,  we  must  correct 
obvious  deformities,  especially  flat-foot,  which  alone  often  renders  the 
patient's  life  utterly  miserable.  We  must  extend  contracted  knees, 
and  hold  them  extended  on  proper  splints. 

Hypertrophic  arthritis  is  even  more  resistant  to  local  treatment  than 
is  atrophic  arthritis,  because  hypertrophic  arthritis  is  characterized  b}' 
mechanical  ankylosis  due  to  bone  proliferation.     In  this  last  type 

^  Edwin  A.  Locke  and  Robert  B.  Osgood,  The  Treatment  of  Non-tuberculous 
Chronic  Arthritis,  Jour.  Amer.  Med.  Assoc,  February  2,  1907. 


950  MIXOI{    SUIUiERY — DISEASES   OF   STKUCTLHE 

forced  motion  and  passive  movements  are  apt  to  do  more  harm  than 
good,  though  massage  and  hyperemia  may  give  rehef.  Our  princi]nil 
resource  is  mechanical  suppoit  for  the  mild  cases,  adhesive-plaster 
strapping,  and  flannel  bandages;  for  the  severe  cases  fixation  in  leather 
splints  or  plaster  spHnts.  Thus  b}-  reducing  the  local  irritation  of  the 
soft  i)ai-ts,  there  may  be  secured  some  return  to  painless  function. 
Occasionally,  when  the  j-ray  shows  conspicuous  bone  overgrowths 
locking  the  joints,  we  may  operate  to  remove  such  growths,  and  then 
continue  the  treatment  b}'  fixation. 

I  have  said  that  the  prognosis  of  chronic  arthritis  is  progressively- 
bad.  Locke  and  Osgood  seem  to  take  a  less  pessimistic  view,  for  the}' 
say:  "We  can  no  longer  consider  this  group  of  diseases  as  hopelessly 
incurable.  The  success  of  modern  therapy  offers  the  greatest  encourage- 
ment. ...  In  cases  of  simple  villous  arthritis,  after  a  fair  trial  of 
conservative  methods,  radical  operation  is  advised.  In  the  infectious 
eases  early  motion  and  as  little  fixation  as  possible  are  indicated.  In 
the  atrophic,  a  judicious  combination  of  fixation  and  motion  affords  the 
greatest  relief,  and  in  the  hypertrophic,  partial  or  complete  fixation  with 
as  little  motion  as  possible  most  favorably  arrests  the  process."  Let  us 
trust  that  these  views  will  be  justified  by  further  experience. 

Tuberculosis  of  the  joints  is  probably  the  largest  subject  which 
confronts  the  orthopedic  surgeon — and  it  still  concerns  the  general 
surgeon  as  well,  especially  in  its  later  manifestations.  General  surgeons 
have  not  yet  ceased  to  excise  and  to  amputate  for  the  cure  of  tubercu- 
lous joints. 

Joint  tuberculosis  has  been  recognized  for  upward  of  one  hundred 
years.  Brodie  and  Nelaton  were  among  the  early  writers  on  the  subject ; 
while  Virchow,  Rokitanski,  and  other  continental  investigators  said 
much  about  the  prevalence  of  bone  and  joint  tuberculosis. 

We  used  to  talk  of  ''white  swelling,"  meaning  tuberculosis  of  the 
knee-joint  in  the  modern  sense.  Now  we  have  learned,  through  the 
researches  of  Nichols  especially,  that  tuberculosis  infects  the  joints 
secDndarily  from  a  tuberculous  focus  in  an  adjacent  epiphysis.  The 
disease  is  of  hematogenous  origin — first,  the  blood-stream,  second,  the 
ep^iphyses,  third,  the  joint.  The  process  reaches  the  joint  either  by 
erosion  of  the  joint  cartilage  or  by  extension  along  the  ligaments.  Then 
the  bacilli  are  set  free  within  the  joint  cavity,  when,  through  the  syno- 
vial fluid  as  a  medium,  and  by  the  action  of  the  limb,  they  are  worked 
thoroughly  into  the  recesses  of  the  joint. 

It  is  needless  to  describe  in  minute  detail  the  pathology  of  the  dis- 
ease further  than  to  state  that  all  parts  of  the  joint  caseate  and  break 
down.  The  serosa  is  destroyed,  the  ligaments  are  infiltrated  and 
weakened,  and  the  cartilages  and  bones  are  eroded.  In  advanced  cases 
the  surrounding  stnictures  take  part  in  the  tuberculous  disease,  when, 
by  the  formation  and  coalescence  of  tubercles  in  these  soft  tissues,  an 
abscess  may  develop  of  the  so-called  "cold-abscess"  type. 

ITnlike  those  joints  the  seats  of  acute  pyogenic  infections,  or  those 
joints  involved  in  chronic  arthritis,  tuberculous  joints  may  heal,  for 


THE    JOINTS  961 

tuberculosis  is  a  self-limited  disease,  and  if  the  active  process  ceases, 
repair  nuxy  occur.  Ilei)air  is  brought  about  by  the  formation  of  a  granu- 
lation  tissue  which  springs  from  that  reactive  granulation  tissue  sur- 
roinuling  all  tuberculous  lesions.  The  new  granulation  tissue  then 
encapsulates  or  grows  into  and  absorbs  the  tuberculous  areas.  As  a 
result  of  this  process,  the  joint  surfaces  may  become  adherent  to  the 
fibrous  tissue,  so  that  a  fibrous  ankylosis  is  established,  or  if  the  process 
has  advanced  still  further,  the  adjacent  bone  surfaces  may  become 
adherent  in  a  bone  ankjdosis,  and  the  joint  cavity  may  be  obliterated. 
In  spite  of  such  apparent  healing,  however,  it  often  happens  that 
diminutive  tuberculous  foci  remain  encapsulated  in  the  neighborhood 
of  the  joint.  In  later  years  these  foci  may  become  active  and  give 
rise  to  a  genuine  recurrent  tuberculosis.  Clinical  experience  has 
taught  us  that  the  reparative  process  is  much  more  vigorous  in  chil-/, 
dren  than  in  older  persons.  The  tuberculous  hip  or  knee  of  a  six-year- 
old  child  may  be  cured  through  open-air  ti-eatment,  fixation,  and  good 
feeding;  the  tuberculosis  of  a  young  adult  may  be  cured  through  an 
erasion  or  excision  of  the  joint,  but  the  older  the  individual,  the  less 
certainly  can  we  count  upon  a  successful  outcome  of  our  therapeutic 
endeavors. 

The  sy7nptovis  and  signs  of  joint  tuberculosis  are  in  general  the  same 
for  all  joints,  but  the  careful  student  of  the  disease  must  learn  to  recog- 
nize special  signs  for  the  lesions  of  special  joints.  The  patient  suffers 
from  general  systemic  complaints — emaciation,  impaired  appetite  and 
digestion,  weariness,  hectic  fever.  Leukocytosis  is  rare.  Moreover, 
tuberculous  disease  of  the  joints  takes  on  certain  characteristic  mani- 
festations, so  that  Konig  divides  the  disease  into  three  types  or  classes : 
tuberculous  hydrops,  granulating  tuberculous  arthritis  (fungus  articuli, 
tumor  albus),  and  suppurative  tuberculous  arthritis. 

Tuberculous  hydrops  is  most  frequently  observed  in  adults,  espe- 
cially in  the  knee-,  ankle-,  and  elbow-joints,  while  the  symptoms  usually 
develop  gradually,  rarely  acutely.  A  serous  exudate  fills  the  joint,  wath 
a  resulting  distention  and  the  evidences  of  fluctuation.  The  diagnosis 
of  the  condition  is  not  always  easy.  The  swelling  and  the  consequent 
limitation  of  motion  are  not  especially  characteristic,  so  that  the  clin- 
ician may  be  driven  to  aspiration  of  the  fluid  and  its  injection  into  an 
animal.  This  form  of  tuberculosis  may  disappear  gradually,  and  there 
may  be  spontaneous  healing,  but  recurrences  of  the  disease  are  common. 
Tuberculous  hydrops  may  be  the  first  form  or  the  forenmner  of — 

Granulating  tuberculous  arthritis — the  common  form  of  joint  tuber- 
Qulosis,  The  joint  affected  b}"  this  disease  tends  to  assume  a  character- 
istic spindle  shape,  as  soft  masses  of  granulating  tissue  invade  and 
surround  the  articulation.  These  masses  give  to  the  palpating  finger  a 
sense  of  indistinct  fluctuation,  which  may  resemble  the  true  fluctuation 
of  tuberculous  hydrops.  Again,  the  sw^elling  may  be  hard  and  resistant 
as  cicatrization  takes  place,  w^hile  the  overljdng  adherent  skin  is  tense, 
shining,  and  anemic  (tumor  albus).  The  joint  may  heal  with  extensive 
cicatrization,  but  the  bones  commonly  are  left  ankylosed,  and  often  in 

61 


9G2  MINOR    SURGERY — DISEASES    OF    STRICTIRE 

bad  position,  unless  proper  treatment  has  been  employed.  These 
malpositions  are  due  to  muscular  contractures.  Sometimes  the  granu- 
lations do  not  cicatrize  promptly,  but  break  down  and  suppurate,  so 
that  abscesses  and  fistula*  develop.  This  is  the  condition  especially 
■which  gives  rise  to  a  fluctuating  hectic  fever. 

We  often  see  this  form  of  tuberculosis  in  knee-  and  ankle-joints. 
The  tibia  becomes  permanently  dislocated  backward  (subluxation), 
while  characteristic  sinuses  appear  in  its  neighborhood. 

The  clinician  must  not  confuse  early  fungous  tuberculosis  of  the 
joint  with  a  sarcoma  of  bone  developing  in  the  neighborhood  of  the  joint. 
Generally  the  x-ray  will  determine  the  diagnosis. 

Suppurath''c  tuberculous  arthritis  (cold  abscess  of  the  joint)  is  not 
common.  Konig  maintains  that  it  is  secondar}'  to  a  primary  synovial 
tuberculosis,  while  other  observers  believe  that  this  synovial  tubercu- 
losis is  itself  an  early  sequel  of  epiphyseal  disease. 

The  three  forms  of  tuberculous  arthritis  are  not  so  readily  distin- 
guishable, however,  as  writers  seem  to  maintain.  Tuberculous  joint 
disease  may  take  on  one  or  all  of  the  characteristics  we  have  described, 
and  the  various  forms  may  nin  into  and  overlap  each  other. 

The  outcome  of  a  tuberculous  arthritis  is  dependent  on  many  fac- 
tors— upon  the  patient's  general  condition,  upon  his  environment,  upon 
the  dissemination  of  tuberculosis  in  the  individual,  and  very  largely 
upon  treatment.  Those  persons  who  die,  die  of  tuberculosis  of  the 
viscera,  of  exhaustion,  and  of  amyloid  degeneration.  Or  they  maj^ 
die  of  an  acute  general  miliary  tuberculosis  or  of  septicemia  following 
a  mixed  infection.  Age  also  has  a  bearing  on  the  prognosis,  as  we  have 
already  observed.  Children  below  the  age  of  fifteen  have  a  better  out- 
look than  adults.  Rarely  is  the  function  of  the  joint  restored  com- 
pletely.    A  limitation  of  motion  is  common  and  ankylosis  is  frequent. 

The  treatment  of  joint  tuberculosis  is  a  subject  which  we  may  not 
here  consider  in  complete  detail,  for  the  care  as  well  as  the  determina- 
tion of  tuberculosis  of  special  joints  is  a  great  topic,  for  the  study  of 
which  I  must  refer  the  reader  to  special  works  on  orthopedic  surgery. 
In  general  terms,  however,  the  clinician  must  employ  two  inevitable 
measures  in  all  forais  of  tuberculous  arthritis.  He  must  enjoin  an 
open-air  life  for  the  patient  and  he  must  place  the  joint  at  rest.  Recent 
studies  in  sanatoria,  and  especialh'  in  the  Convalescent  Home  of  the 
Boston  Children's  Hospital,  have  demonstrated  beyond  question  the 
immense  and  life-saving  value  of  out-of-doors  living  for  these  unfor- 
tunates. The  routine  is  j^ossible  in  severe  climates  even,  where  both 
children  and  adults  quickly  adapt  themselves  to  and  learn  to  enjoy 
this  rather  novel  mode  of  existence.  The  best  of  food  and  forced 
feeding  even  must  be  employed  also,  while  general  tonics  and  the  proper 
care  of  the  skin,  bladder,  and  bowels  must  never  be  neglected. 

Local  treatment  of  joint  tuberculosis  is  almost  as  important  as  the 
general  treatment.  We  have  seen  that  tuberculous  arthritis  tends  to 
heal  spontaneously.  For  this  reason  the  surgeon  must  not  rush  into 
operative  treatment,  but  must  employ  conservative  methods  in  the 


THE    JOINTS  963 

beginning  of  an  attack  of  joint  tuberculosis.  He  may  be  forced  to 
operate  later.  By  conservative  methods  we  mean  mechanical  treat- 
ment: Fixation  of  the  affected  joint;  protection  of  the  joint  from 
bearing  weight :  traction  which  shall  separate  the  diseased  joint  surfaces, 
and  shall  minimize  that  wearing  awa}'  of  the  articular  surfaces  which  is 
mduced  by  the  constant  normal  pull  of  the  muscles.  If  the  joints 
of  the  leg  are  at  fault,  we  must  keep  the  patient  in  bed,  and  we  generally 
can  secure  rest  and  fair  traction  by  applying  plaster-of-Paris  bandages. 
Observe,  however,  that  it  is  well  to  overcome  the  traction  of  the  muscles 
by  a  period  of  weight -and-puUey  treatment  before  the  plaster-of-Paris 
is  applied.  The  plaster  bandage  should  be  changed  after  six  or  eight 
weeks,  when  the  skin  should  be  thoroughly  cleansed  and  powdered, 
and  all  sores  and  abrasions  should  be  treated.  Should  fistula  form 
alwut  the  joint,  we  must  provide  for  their  care  and  their  discharges  by 
cutting  windows  through  the  plaster  over  them. 

When  the  painful  stage  has  passed,  often  after  many  months,  and 
when  the  swelling  has  subsided,  we  may  reapply  a  snug  plaster  or 
other  proper  local  apparatus  and  allow  the  patient  to  go  about  on 
crutches.  If  the  disease  is  in  a  joint  elsewhere  than  the  leg,  we  need 
never  keep  the  patient  in  bed  unless  his  prostration  is  extreme. 

Surgeons  may  find  occasion  to  employ  local  measures  which  shall 
supplement  apparatus.     Bier's  passive  hyperemia  is  coming  mto  con- 
stantly- wider  use,  especially  in  the  early  stages  of  joint  disease,  and  is 
followed  frequently  by  marked  benefit.     As  to  tubercvlo-opsonic  vac-  , 
ernes— their  use  is  still  in  the  experimental  stage,  but  promises  benefit,  """ 
especially  when  they  are  combined  with  other  appropriate  vaccines 
in  cases  of  mixed  infection.     The  use  of  the  x-ray  in  cases  of  tuberculous  ^ 
arthritis  is  still  sub  judice  also^the  exposure  of  the  affected  joint  con- 
tinuously to  the  action  of  the  rays — while  compression  of  the  joint  by 
a  flannel  bandage  is  sometimes  serviceable  in  the  wrist,  knee,  and 
ankle,  in  addition  to  the  measures  I  have  alread}-  described. 

The  operative  treatment  of  tuberculous  arthritis  should  be  reserved 
for  special  and  advanced  cases  of  the  disease.  The  question  often  ^ 
arises  whether  or  not  we  should  operate  on  a  seriously  diseased  joint 
M-hen  there  is  tuberculosis  of  some  of  the  viscera  also — of  the  lung  or  the 
kidney.  We  are  justified  in  operating  on  tuberculous  joints  in  those 
cases  only  in  which  there  is  reasonable  ground  for  hope  that  such  a 
delimitation  of  an  extensive  joint  disease  may  give  the  patient  a  chance 
to  rally  so  that  the  visceral  tuberculosis  may  have  a  better  opportunity 
of  healing. 

Operations  on  tuberculous  joints  should  be  performed  with  the 
parts  made  dry  by  an  artificial  ischemia  through  the  use  of  a  tourniquet, 
and  we  should  make  incisions  which  shall  expose  thoroughly  all  of 
the  diseased  parts.  There  are  several  special  methods  ofoperating. 
We  employ  mcision  of  the  joint  to  relieve  tension,  especially  in  the 
deep-seated  joints;  to  evacuate  an  abscess;  or  to  explore  a  joint  for 
the  sake  of  diagnosis  even  and  for  the  removal  of  sequestra.  At  the 
best,  hoM-ever,  a  simple  incision  has  little  or  no  effect  as  a  curative 


964  MINOR    SURGERY — DISEASES    OF    STRlCTrRE 

measure;  indeed,  iifter  incision  we  must  look  for  ii  subsecjuent  mixed 
infection  of  the  wound,  und  this  prospect  must  render  us  extremely 
cautious  of  such  an  exploration. 

We  practice  evasion,  as  it  is  called  (arthrectomy) ,  for  the  purpose 
of  removing  the  whole  of  the  diseased  tissue,  and  we  employ  erasion 
in  the  cases  of  children  chiefly,  for  whom  we  must  make  every  effort  to 
save  their  epiphyseal  lines,  so  as  not  to  curtail  the  growth  of  the  limb. 
After  erasion  we  look  for  ankylosis.  We  perform  this  opei-ation  with 
the  knife,  scissors,  and  curet,  and  remove  all  the  diseased  tissue  which 
we  can  reach — especially  and  most  carefully  all  of  the  synovial  mem- 
brane, spooning  away  tubercvilous  foci  in  the  adjacent  bones.  If  we 
find,  however,  that  the  Ijones  themselves  are  extensively  diseased,  we 
must  go  further  and  perform — 

Excision  of  the  joint  (resection),  limiting  this  operation,  however, 
as  far  as  possible,  to  adult  patients.  We  must  always  bear  in  mind 
that  excision  is  to  be  employed  for  the  most  severe  cases  only — when 
"mechanical  treatment"  has  failed;  when  there  are  large  sequestra; 
when  drainage  and  erasion  seem  useless;  and  when,  with  a  rapidly 
failing  general  condition,  the  extreme  operation  of  excision  seems  in- 
evitable. It  is  one  of  the  operations  of  last  resort.  A  further  opera- 
tion of  last  resort  is  amputation,  especially  in  the  case  of  adults  and 
when  there  coexists  visceral  tuberculosis,  or  extensive  and  obstinate 
mixed  infections. 

It  is  needless  here  to  describe  in  detail  all  the  numerous  operations 
which  the  surgeon  may  perform  upon  special  joints,  but  it  is  well  to 
discuss  certain  resections — resections  of  the  elbow,  the  wrist,  the  hip, 
the  knee,  and  the  ankle,  especially  since  these  joints  sometimes  are 
resected  for  conditions  other  than  tuberculosis. 

Excision  of  the  elbow  may  be  accomplished  through  various  incisions 
— Langenbeck's  long,  straight  incision,  with  its  middle  point  over 
the  olecranon;  Ollier's  bayonet-shaped  incision,  as  illustrated  in  the 
text,  and  Kocher's  J-shaped  incision.  All  these  incisions  are  designed 
to  give  free  access  not  only  to  the  elbow-joint  itself,  but  to  the  soft  parts 
about  it.  Perhaps  Kocher's  incision  accomplishes  this  object  most 
effectively,  though  the  straight  incision  is  the  common  and  popular 
incision  among  American  surgeons. 

The  patient  lies  on  his  back;  the  elbow  is  held  in  flexion,  with  the 
arm  across  the  patient's  chest.  We  carry  the  cut,  about  six  inches 
long  in  the  long  axis  of  the  arm,  down  upon  the  humerus,  the  olecranon 
fossa,  the  olecranon  process,  and  the  posterior  surface  of  the  ulna; 
we  expose  the  bones  thoroughly,  and  then,  with  periosteal  instruments, 
scrape  away  from  them  all  the  soft  parts  until  the  posterior  aspect 
of  the  joint  is  laid  bare.  The  great  ulnar  nerve,  lying  behind  the 
internal  condyle,  is  the  one  important  structure  to  l^e  avoided.  Fre- 
quently we  are  able  to  turn  aside  all  the  soft  parts  without  even  seeing 
this  nerve.  The  incision  has  split  the  triceps  muscle  and  its  tendinous 
insertion,  but  its  extension  into  the  deep  fascia  of  the  forearm  must  be 
preserved   carefully.     We   now   have   the   bones   everywhere   exposed 


THE    .lOINTS 


965 


except  upon  their  anterior  surfaces.  Open  the  joint  from  behind, 
force  the  end  of  the  humerus  out  through  the  wound,  grasp  it  with 
lion  forceps,  and  cut  it  squarely  off.  Then  perform  the  same  maneuver 
with  the  bones  of  the  forearm — the  upper  end  of  the  ulna  and  the  head 
of  the  ratlins.  This  disposes  of  the  diseased  bone,  but  the  surgeon 
must  not  close  the  wound  without  inspecting  carefully  all  the  neighbor- 
ing soft  parts,  and  removing  thoroughly  with  the  knife  and  scissors 
ever}'-  suspicious  focus. 

Our  ultimate  object  in  performing  excision  of  the  elbow  is  to  provide 
the  patient  with  a  healthy  flail  joint — often  an  extremely  strong  and 


Fig.  655. — Excisions  about  elbow:  A, 
Excision  of  elbow-joint  by  posterior 
median  incision  (Langenbeck's  opera- 
tion); B,  B',  excision  of  elbow-joint  by 
radial  and  ulnar  lateral  incisions;  C, 
excision  of  superior  radio-ulnar  articu- 
lation by  posterior  vertical  incision 
(Bickham). 


Fig.  656. — Excisions  about  elbow:  A, 
Excision  of  elbow-joint  by  bayonet- 
shaped  incision  (Ollier's  operation):  B, 
ulnar  incision,  added  to  bayonet-shaped 
incision,  if  needed  (Bickham). 


useful  joint.  In  order  to  secure  this  we  must  suture  carefully  with  cat- 
gut the  various  soft  parts  in  layers,  must  drain  the  wound,  and  must 
fix  it  finalh^  and  firmly  upon  a  right-angled  splint  with  the  severed 
bone-ends  well  separated,  lest  bony  ankylosis  subsequently  occur.  The 
operation  is  not  difficult,  and  the  surgeon  should  perform  it  so  care- 
hiWy  as  to  avoid  damage  to  essential  muscles,  tendons,  nerves,  and 
vessels.  Ten  days  after  the  operation  we  must  begin  massage  and 
gentle  passive  motions,  and  may  look  for  a  fairly  useful  joint  at  the  end 
of  two  months. 

The  urist-joint  excision  is  performed  commonly  through  the  single 
dorsoradial    incision — the    Boeckel-Langenbeck    operation.     Make    a 


966  MIXOR    SURGERY — DISEASES    OF    STRUC'TTRE 

straight  incision  along  the  back  of  the  radius  between  the  extensor 
communis  (Hgitorum  and  the  extensor  longus  jjoUicis  tendons;  this 
incision  extends  from  the  lower  half  of  the  second  metacarpal  up  over 
the  radius  to  about  two  inches  above  the  joint.  In  making  the  incision 
we  must  avoid,  if  possible,  the  radial  nerve  branches  running  to  the 
middle  finger.  Now  deepen  the  incision  toward  the  second  metacarpal, 
the  trapezoid,  the  scaphoid,  the  joint  capsule,  the  posterior  annular 
ligament,  and  the  radius;  tlrawing  aside  the  tendons  ^\•hich  come  into 
view,  and  dealing  with  the  soft  parts  and  involved  tendons  by  excision, 
how^ever,  if  their  retention  seems  impossible.  P'rom  this  point  on  we 
handle  diseased  bone,  stripping  back  the  periosteum  and  ligaments  so 
far  as  seems  wise;  removing  the  involved  carpal  bones;  freeing  the 
ends  of  the  radius  and  ulna,  turning  them  out  of  the  wound  by  strongly 
flexing  the  hand,  and  sawing  off  their  involved  ends.  The  after-care 
of  this  wound  is  simple,  and  consists  in  immobilizing  the  arm  and  hand 
in  a  plaster  sjilint  for  two  or  three  weeks.  We  aid  later  in  restoring 
function  by  gentle  massage  and  gradually  increased  active  and  passive 
movements.  The  resulting  wrist  is  often  extremely  useful.  Fair 
strength  may  be  restored  to  it,  and  in  favorable  cases  a  somewhat 
movable  joint  even  may  be  recovered. 

Excision  of  the  hip-joint  may  be  expected  to  result  in  a  useful  limb. 
Ankylosis  is  the  exception,  though  there  is  always  some  atrophy  and 
some  shortening  of  the  leg.  Langenbeck's  straight  incision  operation 
is  the  operation  generally  serviceable.  With  the  patient  lying  on  his 
sound  side,  the  affected  thigh  is  flexed  at  an  angle  of  45  degrees  and 
rotated  inward;  the  surgeon  cuts  down  in  the  axis  of  the  femur  upon 
the  great  trochanter,  making  an  incision  about  six  inches  in  length. 
This  cut  passes  through  the  skin,  the  fascia,  and  the  gluteus  maximus, 
when  the  gap  between  the  gluteus  medius  in  front  and  the  pyriformis 
behind  is  sought,  and  widened  by  retraction.  Thus  we  expose  the 
capsule  of  the  joint  and  divide  that  structure  down  to  the  bone.  With 
a  curved  periosteal  elevator  raise  the  anterior  and  posterior  periosteal 
flaps;  then  cut  the  cotyloid  ligament  with  a  knife  thrust  within  the 
rim  of  the  acetabulum,  wdien  air  wall  enter  the  joint  and  allow  the 
joint  surfaces  to  be  separated.  Next  raise  and  cut  away  the  muscles 
attached  to  the  great  trochanter,  while  an  assistant  grasping  the  knee  and 
foot  rotates  the  thigh  outward.  Then  divide  the  ligamentum  teres 
and  dislocate  the  head  of  the  l)one  either  forward  or  backward.  Saw^ 
off  the  bone,  usually  below  the  great  trochanter,  with  slight  obliquity 
from  above  downward  and  from  without  inward.  Scrape  out  the 
acetabulum ;  trim  away  all  the  synovial  membrane  and  all  suspicious 
tissue;  drain  the  joint;  suture  the  capsule,  the  muscles,  and  the  skin, 
and  put  up  the  leg  in  extension  with  a  weight  and  pulley. 

The  crippled  leg  must  be  kept  at  rest  and  in  extension  for  man}' 
weeks.  Gradually,  how^ever, — perhaps  in  six  weeks,  when  a  false  joint 
has  formed  and  the  wound  has  healed, — we  ma}'  proceed  actively  W'ith 
massage  and  movements,  reasonably  expecting  to  secure  good  use  of 
the  leg. 


THB    JOINTS 


967 


Excision  of  the  knee-joint  has  come  to  be  regarded  as  an  almost 
classic  operation.  Twenty  years  ago  the  old-fashioned  open  incision 
— still  popular — was  familiar  to  all  students.  Last  year  I  was  sur- 
prised to  learn  from  ten  members  of  the  Harvard  graduating  class  that 
not  one  of  them  had  seen  an  operation  for  excision  of  the  knee.  Our 
reflection  on  this  statement  must  be  that  the  radical  operations  for 
tuberculous  arthritis  are  less  common  than 
they  were  in  the  student  days  of  the  last 
generation. 

The  excellent  and  familiar  excision  of 
the  knee-joint  by  the  open  method  is  per- 
formed in  a  fashion  not  dissimilar  to  that 
of  excision  of  the  elbow-joint.  With  the 
patient  on  his  back  and  his  leg  extended, 
apply  a  tourniquet  and  make  a  curved 
transverse  incision,  passing  either  above  or 
below  the  patella ;  turn  back  the  skin-flap ; 
open  the  joint  by  means  of  a  deep  trans- 
verse cut  above  the  head  of  the  tibia;  flex 
the  knee  firmly,  bringing  the  heel  up  to 
the  buttock;  strip  back  the  soft  parts  from 
the  femur — the  soft  parts  both  within  and 
without  the  joint ;  remove  the  patella,  thus 
freeing  the  femur,  which  may  easil}''  be 
dra"v^^l  outside  of  the  wound;  saw  off  the 
necessary  amount  of  bone.  Now  trim  the 
tibia  in  similar  fashion;  scrape  back  the 
soft  parts  before  and  behind ;  expose  thor- 
oughly the  head  of  the  tibia  and  saw  it  off 
smoothly,  and  in  such  a  way  that  its  cut 
surface,  when  brought  into  apposition  with 
the  cut  surface  of  the  femur,  will  lie  straight 
and  evenly  against  it  at  right  angles  to  the 
shaft  of  the  bone.  Trim  off  thoroughly  all 
diseased  soft  parts ;  remove  the  tourniquet ; 
secure  perfect  hemostasis;    wire  the  two 

bones  together  at  two  or  three  points,  and  put  up  the  limb  on  a  splint 
which  shall  provide  for  drainage  after  the  wound  has  been  closed  in 
layers.  Our  object  in  excising  the  knee-joint  is  to  secure  a  sound  leg 
with  ankylosis — an  object  directly  the  reverse  of  the  object  looked  for 
after  excising  the  elbow  or  the  hip,  in  which  we  aim  at  a  movable  joint. 

We  must  keep  the  leg  fully  extended  on  a  splint  for  from  six  weeks 
to  three  months,  and  must  prescribe  crutches  for  many  months  there- 
after. If  we  succeed  in  curing  the  tuberculosis,  the  patient  may  expect 
to  walk  strongly  with  a  stiff  leg  and  a  Hmp,  as  the  least  possible  evil. 

Excision  of  the  knee-joint  by  the  closed  method,  as  devised  by  Flint/ 

1  Carleton  P.  Flint,  A  New  Method  of  Excision  of  the  Knee- Joint  without  Open- 
ing the  Joint,  Ann.  Surg.,  March,  1906. 


Fig.  657.^ — Excision  of  knee- 
joint:  By  anterior  U-shaped 
incision  (Bickham). 


9()8 


MINOR    ST'RGEHY — DISEASES    OF    STIM'CTUHE 


has  been  suininfi  in  favor  during  the  past  four  years.  His  proposition 
and  purpose  are  to  remove  the  diseased  mass  of  bone  and  cartilage 
without  opening  the  mass  and  soihng  the  surrounding  structures.  He 
removes  the  knee  with  a  wide  margin,  as  one  would  remove  a  mass  of 
malignant  tlisease.  The  method  is  ingenious  and  effective,  and  is  well 
illustrated  by  the  sketches  in  the  text,  adapted  from  Flint's  article. 

The  long  U-shaped  skin  incision  exposes  a  large  surface  of  soft  parts; 
the  short  U-shaped  incision  through  the  rectus  muscle  permits  of  the 
turning  up  of  that  attachment  above  the  outside  of  the  joint  pouch, 
thus   exposing   the   pouch   or   subcrural   bursa.     The   oblique   lateral 


Fig.  658. — Flint's  excision — square  incision  in  .skin:  (i,  External  lateral  inci- 
sion; b,  tubercle  of  tibia;  c,  internal  lateral  incision;  d,  patella;  e,  transverse  incision 
(Flint,  in  Annals  of  Surgery). 

incisions  free  the  remaining  muscular  attachments  from  the  femur. 
The  operator  does  not  bend  the  patient's  knee,  but  cuts  through  the 
head  of  the  tibia  with  the  leg  extended.  He  cuts  through  upon  a  metal 
director  or  guard  which  previously  has  been  slipped  behind  the  head 
of  the  bone.  Then  he  seizes  the  head  of  the  bone,  flexes  the  leg  back- 
ward, and  frees  the  soft  parts  behind  the  joint  until  he  is  well  above 
the  condyles  of  the  femur :  "  As  soon  as  the  posterior  region  of  the  con- 
dyles is  exposed,  the  femur  is  sawed  through  from  behind  fonvard  and 
slightly  downward  at  a  level  sufficient  to  clear  the  cartilages  behind. 
This  saw-cut  is  carried  fol'^\'ard  until  it  reaches  the  margin  of  the  cartilage 
on  the  anterior  surface  of  the  femur,  when  the  saw  is  withdrawn.     .     .     . 


THE    JOINTS 


9G9 


It  is  easy  to  be  deceived  as  to  the  exact  position  of  the  cartilage  behind. 
One's  examination  should  be  particularly  careful  at  this  stage  of  the 
operation,  lest  the  cut  in  the  femur  be  made  too  wide.  After  with- 
drawing the  saw  from  the  femur,  the  leg  is  once  more  placed  in  a  hori- 
zontal position.  The  saw  is  then  introduced  in  front,  behind  the 
subcrural  bursa  at  the  upper  margin  of  the  articular  cartilage,  and  a  cut 
is  made  to  meet  the  posterior  saw-cut."     That  ends  the  operation 


Fig.  659. — Flint's  excision:  U-shaped 
incision  in  quadriceps  extensor;  internal 
and  external  lateral  excisions  in  facial 
expansion  of  quadriceps.  Transverse 
incision  over  head  of  tibia:  a,  Skin-flap 
turned  up;  b,  quadriceps  extensor  ten- 
don; d,  joint;  e,  patella;  /,  transverse 
incision;  g,  U  shaped  muscle  incision; 
h,  internal  lateral  incision;  i,  joint;  /, 
patellar  tendon;  A",  tubercle  of  tibia 
(Flint,  in  Annals  of  Surgery). 


Fig.  660. — Flint's  excision — muscie^ 
incisions;  bursa  turned  down;  retractor 
in  place  and  saw  cutting  tibia;  a,  Re- 
tracted skin- flap;  b,  femur;  c,  subdural 
bursa;  e,  patella;  /,  quadriceps  extensor 
turned  up;  g,  vastus  internus;  h,  re- 
tractor belund  tibia  (Flint,  in  Annals  of 
Surgery) . 


practically,  for  the  surgeon  may  now  lift  out  entire  the  mass  of  tuber- 
culous disease,  wire  the  bones  together,  and  treat  the  limb  as  after  the 
ordinary  open  excision. 

Excision  of  the  ankle-joint  is  an  easy  matter  and  scarcely  warrants  a 
detailed  description  after  one  has  mastered  the  principles  of  joint 
excisions  as  we  have  already  described  them.  The  incision  for  the 
operation  is  made  behind  and  below  the  astragalus  on  the  outer  side. 
The  incision  is  curved  so  as  to  permit  of  a  free  skin  retraction.     Then 


970 


MINOR    SURGERY— DISEASES    OF    STRUCTURE 


the  deeper  parts  are  dissected  u\>\  the  tendons  held  aside;  the  joint 
opened  and  disarticulated,  and  the  involved  bones  and  soft  parts  re- 
moved. Diseased  foci  in  the  tibia  and  fibula  call  for  remcn-al  of  the 
ends  of  those  bones.  Diseased  foci  in  the  small  bones  of  the  tarsus 
call  for  the  extirpation  of  the  small  bones  involved.  Excision  of  the 
ankle-joint  frequently  fails  of  its  purpose;  the  disease  may  retui-n, 
while  at  the  best  we  must  look  for  healing  with  ankylosis  and  a  deformed 
and  crippled  foot. 


Fig,  661  —  Flint  s  excision — tibia 
cawed  through;  leg  flexed;  structures  at 
knee  above  fallen  into  place  a,  Patella; 
h,  patellar  tendon;  r,  popliteal  struc- 
tures; d,  patellar  tendon;  e,  skin-flap 
turned  up;  /,  patellar  tendon;  g,  tibia; 
/',  tibia;  /,  tubercle  of  tibia  (Flint,  in 
Annals  of  Surgery  i 


Fig,  662 — Flint's  excision — leg  hori- 
zontal; bursa  turned  down;  saw  in  })lace. 
a,  Retracted  skin-fiap;  6,  femur;  c,  (juad- 
riceps  extensor;  (/,  l5ur.sa  turned  down; 
(',  patella;  /,  saw  cut  in  head  of  tibia; 
y,  retractor  (Flint,  in  Annals  of  Sur- 
gery) 


I  shall  not  describe  excisions  of  other  joints,  for  the  principles  are 
already  indicated,  and  are  they  not  all  described  at  length  in  countless 
volumes  of  operative  surgery? 

Coxa  Vara.* — Strangely  enough,  the  term  coxa  vara  does  not  appear 
m  surgical  literature  until  within  recent  years.  Billings'  Medical  Dic- 
tionary^ of  1890  does  not  contain  the  words,  though  the  condition  has 
long  been  appreciated.  Bent  hip  is  a  characteristic  of  rickets,  and  one 
finds  it  described  in  discussions  of  that  disease.  Bent  hip  may  be  due 
to  an  injury  also — traumatic  coxa  vara. 

'  Coxa,  hip;  vara,  bent 


THE    JOINTS  971 

Coxa  vara  is  that  condition  of  the  femur  in  which  the  outer  end  of  the 
neck  of  the  bone  is  forced  upward  so  that  the  trochanter  rides  above 
Nelaton's  line,  while  the  head  of  the  femur  remains  in  the  acetabulum. 
The  patient  notices  at  first  pain  and  a  limp  on  the  affected  side,  while 
the  surgeon  discovers  a  shortening  of  that  leg  unless  the  disease  is 
bilateral;  an  abnormally  high  position  of  the  trochanter;  and  inability 
to  abduct  the  leg.  The  foot  and  leg  are  generally  rotated  outward,  but 
all  the  motions  are  fairly  free  except  abduction. 

If  the  disease  be  present  in  both  hips,  we  discover  a  lordosis  or 
forward  curvature  of  the  lumbar  spine,  to  compensate  for  the  tilting 
of  the  pelvis  caused  by  the  coxa  vara.  The  x-ray  should  discover 
the  exact  position  of  the  femora. 

Traumatic  coxa  vara  may  be  found  at  any  age,  but  especially  in 
childhood.  It  results  from  an  impacted  fracture  of  the  neck  of  the 
femur,  due  to  a  fall  on  the  hip.  The  patient  may  suffer  immediate 
disability,  but  with  time  and  bony  union  a  permanent  deformity  may 
result,  so  that  the  patient  walks  with  a  limp  and  suffers  from  pain  in  the 
joint.  A  child  with  this  disablement  may  have  night  cries,  and  the 
clinical  picture  may  resemble  strongly  that  of  the  early  stages  of  hip 
disease.  We  should  call  in  the  aid  of  the  x-ray  to  settle  every  question 
of  obscure  hip  lesion.  We  must  distinguish  coxa  vara  from  a  congenital 
hip  dislocation  also,  as  weU  as  from  hip  disease. 

Congenital  coxa  vara  is  a  condition  recognized  within  the  last 
fifteen  years  only.^  This  form  of  the  disease  appears  to  have  no  relation 
to  rickets,  but  to  be  due  to  intra-uterine  conditions  through  which  the 
femur  is  adducted  instead  of  being  normally  abducted. 

The  trecdment  of  all  forms  of  coxa  vara  is  directed  toward  restoring 
the  normal  angle  of  the  neck  of  the  femur.  If  the  patient  is  an  infant 
or  young  child,  and  if  the  case  is  recent  and  traumatic,  the  patient 
should  be  anesthetized  and  the  femur  should  be  bent  out  to  the  proper 
angle;  the  leg  should  then  be  held  in  a  plaster-of-Paris  spica  bandage 
for  at  least  two  months,  in  the  new  position.  TMien  the  bandage  has 
been  removed,  the  convalescence  should  be  stimulated  by  massage 
and  by  carefuUy  protected  use  of  the  leg. 

There  are  many  cases  which  do  not  permit  of  the  forcible  correction 
described  above.  In  such  cases  we  should  employ  such  a  protective 
splint  as  is  used  in  cases  of  hip  disease.  The  patient  may  then  go  about 
on  crutches,  with  the  strain  of  weight-bearing  taken  off  the  femur. 
In  extreme  cases  of  the  disease  the  surgeon  may  perform  a  subtrochan- 
teric osteotomy  by  a  linear  incision  throvigh  the  femur  below  the  tro- 
chanter. He  may  then  correct  the  improper  rotation  of  the  leg,  and 
may  hold  the  fragments  in  place  with  a  plaster-of-Paris  bandage  until 
firm  union  has  been  restored.  We  see,  therefore,  that  there  is  much  to 
do  for  cases  of  coxa  vara,  and  that  a  restoration  of  fair  function  maybe 
expected  with  confidence. 

1  Kredel,  in  1896,  was  the  first  observer  to  call  special  attention  to  the  condition; 
and  the  literature  of  the  subject  is  well  summarized  by  Henrj'  O.  Feiss  in  the  Jour. 
Amer.  Med.  Assoc,  February  24,  1906. 


972  MINOR    SURGERY — DISEASES    OF    STRUCTURE 

There  are  many  other  rare  affections  of  the  joints  at  which  avc  must 
glance  briefly. 

Coxa  valga  is  a  condition  the  reverse  of  coxa  vara.  In  coxa  vaiga 
the  angle  of  the  neck  of  the  femur  is  increased.  The  disease  may  be 
either  unilateral  or  bilateral.  It  occurs  as  a  congenital  ailment;  in 
infantile  paralysis;  after  long  disuse  of  the  leg;  after  amputations;  and 
in  rickets  and  osteomalacia.  The  deforniity  is  characteiized  by  an 
outward  rotation  and  abduction  of  the  leg,  with  limitation  of  the  opposite 
movements;  flattening  of  the  trochanter;  lengthening  of  the  leg;  pain  in 
the  hip;  and  a  limp  in  walking.  The  a:-ray  establishes  a  diagnosis. 
So  far  as  treatment  has  been  successful,  it  has  been  by  osteotomy  of  the 
neck  of  the  femur,  and  restoring  the  normal  angle  by  pushing  up  and  nail- 
ing or  wiring  the  shaft  to  the  necrk  at  the  normal  angle. 

Charcot's  disease  is  a  chronic  and  destructive  affection  of  the  joints 
and  is  usually  seen  in  adults.  One  or  many  joints  may  be  involved, 
and  the  symptoms  resemble  those  of  arthritis  defoi'mans — swelling, 
effusion,  loss  of  function,  variable  pain,  and  disintegration  of  the  joint, 
followed  by  laxity  and  dislocation.  Ankyloses  and  suppuration  are 
rare;  and  although  the  disease  is  progressive,  as  a  rule,  it  may  cease 
spontaneously.  The  disease  is  extremely  difficult  of  diagnosis  unless  the 
surgeon  recognizes  the  invariable  underlying  and  coexisting  organic 
nervous  affection,  the  discovery  of  wdiich  is  an  aid  in  determining  Char- 
cot's disease;   w-hile  the  x-ray  is  of  great  value  also,     ^y^^vi.  ■    , 

Treatment  influences  but  little  the  progress  of  the  Ailment;  never- 
theless, we  may  look  for  some  improvement  by  fixation  of  the  joint 
and  by  protecting  it  with  proper  splints  from  damage.  Resection  of 
the  joint  is  of  little  or  no  value,  and  amputation  may  be  followed  by 
a  failure  of  Avound  healing. 

Spondylitis  deformans,  a  chronic  and  progressive  stiffening  of  the 
spine  accompanied  by  pain,  comes  within  the  province  of  the  ortho- 
pedic surgeon,  and  the  student  should  consult  monographs  on  ortho- 
pedic surgery  for  Ji  satisfactory  study  of  this  disease. 

Neuromimesis  of  the  joints,  hysteric  joints,  have  interested  surgeons 
for  many  years,  and  Sir  Benjamin  Brodie  in  the  second  quarter  of  the 
last  century  wrote  the  first  satisfactory  and  convincing  papers  on  the 
subject.  In  spite  of  the  name  w^e  are  coming  to  believe  that  many 
joints  which  seem  to  cause  great  pain  "without  a  deformity  or  organic 
Q_^  lesion  may  not  always  be  assigned  to  the  hysteric  class,  since  we  may 
at  times  discover  in  these  joints  slight  grades  of  arthritis  deformans. 
Young  women  are  the  common  sufferers  from  neuromimesis.  There 
is  often  a  story  of  injury;  sometimes  there  are  medicolegal  complica- 
tions, and  then  a  long  history  of  pain  and  debility,  with  little  or  no 
apparent  anatomic  cause.  Every  experienced  surgeon  is  familiar  with 
these  cases,  and  recognizes  in  them  either  malingery  or  a  highly  emo- 
tional temperament.  Moreover,  one  should  look  in  the  patient's  eyes 
for  errors  in  refraction,  and  should  investigate  the  (ondition  of  her 
pelvic  organs.  A  careful  neurologic  study,  based  on  the  temperament 
of  the  patient  and  the  history  of  the  case,  is  necessary  to  detei'mine 


THE    JOINTS  973 

positively  the  presence  of  a  hysteric  joint;  or  it  may  be  of  a  neurasthenic 
spine. 

It  is  needless  here  to  discuss  in  detail  the  complex  and  extensive 
subject  of  treatment  for  hysteric  joints.  Treatment  largely  is  general 
and  moral — the  building  up  of  health,  the  improvement  of  the  appetite, 
the  regulation  of  functions,  and  the  bringing  of  the  patient  to  a  realiza- 
tion of  her  true  condition.  In  addition  we  prescribe  such  common- 
place factors  in  right  living  as  an  open-air  life;  cold  bathing;  exercise; 
regular  meals,  and  abundance  of  sleep.  Massage  is  often  of  great 
benefit,  and  the  search  for  and  pursuance  of  a  congenial  and  useful 
occupation. 


CHAPTER  XXXI 


AMPUTATIONS 


I\  the  old  surgeries  the  subject  of  amputations  was  probably  the 
most  important  subject  which  writers  had  to  discuss,  for  in  the  old 
days  before  asepsis  surgery  was  destructive,  mainly.  To-day  it  is  con- 
structive. Twenty-five  years  ago  the  teacher  of  surgical  anatomy 
exercised  his  students  for  weeks  at  amputations  upon  the  cadaver.  To- 
day few  students  learn  how  properly  to  perfoim  an  amputation.  In 
the  old  days  he  was  the  most  skilful  surgeon  who  cut  off  a  limb  with 
the  greatest  despatch  consistent  with  preserving  tissue  enough  to  form 
a  stump;  and  that  despatch  was  a  tradition  inherited  from  the  time 
before  anesthetics  were  known.  To-day,  the  careful  surgeon  amputates 
painstakingly  and  cautiously.  Indeed,  the  most  important  purpose  in 
an  amputation  to-day,  aside  from  the  purpose  of  a  thorough  removal 
of  diseased  tissue,  is  to  provide  the  patient  with  a  painless,  serviceable, 
and  sightly  (sic  !)  stump. 

In  these  days  amputations  are  relatively  infrequent,  because  asepsis 
makes  possible  the  saving  of  limbs  which  would  have  been  sacrificed 
in  old  times.  So  latel}'  as  the  American  Civil  War  nearly  all  compound 
fractures  were  amputated.  To-day  we  amputate  in  traumatic  cases 
only  when  it  is  reasonably  obvious  that  the  soft  parts  of  the  limb  have 
been  damaged  beyond  salvation.  Who  may  say  what  extent  of  tissue 
destruction  shall  render  impossible  the  saving  of  a  limb?  The  answer 
to  this  question  depends  upon  a  variety  of  factors.  A  robust  young 
man  with  sound  heart  and  kidneys,  without  taint  of  syphilis,  tubercu- 
losis, or  diabetes,  may  suffer  a  crushing  injury,  of  extreme  severity  to 
his  leg,  yet  the  conservative  surgeon  may  save  ff)r  him  a  useful  member. 
On  the  other  hand,  the  very  young  or  the  old,  the  alcoholic,  the  diabetic, 
the  syphilitic,  the  victim  of  arteriosclerosis,  after  his  accident  may 
retain  little  power  of  recuperation  for  the  mending  of  a  shattered  limb, 
so  that  an  amputation  is  our  feeble  and  only  resort  in  his  case. 

Such  considerations  are  general  considerations.  Then  there  are 
considerations  of  special  or  local  significance.  The  possil)ility  of 
saving  a  damaged  member  is  dependent  largely  on  the  amount  of  skin 
left  uncrushed.  An  extensive  area  of  sound  and  viable  skin  is  more 
necessary  for  the  preservation  of  a  crushed  limb  than  is  sound  bone 
or  sound  muscle;  and  the  surgeon  must  assure  himself  that  the  circula- 
tion remains  good  in  that  part  of  the  limb  beyond  the  seat  of  damage 
also.  A  just  estimate  of  all  these  factors  will  come  from  practice  and 
experience  only. 

974 


AMPUTATIONS  975 

We  operate  "in  continuity"  when  we  cut  through  the  bone  in  an 
amputation.  We  operate  "in  contiguity,"  or  by  disarticulation,  when 
Ave  remove  the  limb  through  a  joint. 

We  speak  of  amputations  as  "immediate,"  as  "primary,"  and  as 
"secondary."  Immediate  amputations  are  those  which  ai-e  done  at 
once,  while  the  patient  is  still  in  shock,  usually  in  from  one  to  six  hours 
after  the  injury.  Primary  amputations  are  done  after  the  patient 
has  reacted  from  shock,  but  before  an  infection  has  become  manifest — 
usually  within  twenty-four  hours  after  the  injury.  Secondary  amputa- 
tions are  done  at  any  later  period,  and  frequently  after  the  establish- 
ment of  an  infection. 

The  reasons  for  amputations  are  commonly  three:  (1)  A  serious 
crushing  injury;  (2)  a  destructive  tissue  disease  (i.  e.,  tumor;  tuber- 
culosis) ;  (3)  a  deformity  or  mutilation  which  the  amputation  may 
remove  or  correct. 

I  have  already  discussed  in  general  terms  the  traumatic  class  of  cases. 
The  principal  diseases  for  which  we  amputate  are  destructive  osteo- 
myelitis; extensive  chronic  ulcers  of  the  soft  parts;  tuberculosis  or 
advanced  sepsis;  the  gangrene  due  to  vascular  or  diabetic  conditions; 
and  tumors,  usually  of  the  malignant  type.  The  victim  also  of  a  hope- 
lessly deformed  and  useless  hand  or  foot  may  call  for  its  amputation. 

One  sees  from  this  description  that  w^e  may  properly  employ  two 
other  terms  designating  the  urgency  of  an  amputation:  amputations 
of  necessity,  and  amputations  of  expediency.  Furthermore,  according 
as  amputations  are  those  of  necessity  or  expediency,  so  the  technical 
nature  of  the  amputation  may  be  varied.  There  are  the  typical  or 
classic  methods  which  we  employ  when  we  can  operate  at  leisure  and 
follow  the  best  and  most  satisfactory  procedures;  and,  on  the  other 
hand,  in  an  amputation  of  necessity  we  may  be  obliged  to  perform  an 
atypical  operation,  cutting  through  where  we  must,  and  saving  what  we 
can,  in  order  to  secure  a  useful  stump. 

Every  experienced  surgeon  recognizes  a  further  and  marked  pecu- 
liarity of  the  necessary  amputation  as  contrasted  with  the  expedienc}' 
amputation.  The  necessary  amputation  is  done  frequently  upon  a 
robust  person,  active  and  well  up  to  the  time  of  receiving  his  injury. 
His  circulation  is  vigorous,  and  his  reflexes  acute.  As  a  result,  the  ampu- 
tation itself,  in  addition  to  the  shock  of  the  accident,  is  a  serious  affair 
for  him.  Such  a  patient  is  liable  to  become  extremely  prostrated;  to 
suffer  intensely  from  shock;  to  recuperate  slowly;  and  to  experience  a 
tedious  wound  healing.  On  the  other  hand,  in  the  case  of  an  expe- 
diency amputation,  one  observes  frequently  that  the  invalid,  the  victim 
of  localized  tuberculosis  or  malignant  disease,  experiences  little  shock 
from  the  operation.  The  removal  of  the  diseased  member  seems  to  act 
almost  as  a  stimulant.  He  rebounds  at  once  from  the  primary  shock  of 
the  amputation ;  his  general  condition  improves  promptly ;  and  his  wound 
heals  readily  and  kindly,  so  that  one  may  expect  him  to  be  in  better 
general  condition  in  a  few  days  than  he  was  before  the  operation. 

Regarding  the  technic  of  major  amputations,  let  us  consider  three 


976  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

important  issues :  the  questions  of  shock  and  its  control ;  of  hemorrhage 
and  its  control;  and  of  the  molding  of  the  stump. 

The  shock  to  ^vhich  I  refer  is  not  that  shock  which  resulted  from 
the  injury  and  existed  before  the  patient  was  brought  to  us  for  opera- 
tion. That  foim  of  shock  I  have  already  considered  in  Chapter  XXVII 
of  this  book.  Suffice  it  to  remind  the  reader  here  that  opium  and  the 
transfusion  of  blood  are  our  most  valuable  remedies  for  that  shock. 
The  shock  which  occurs  during  the  amputation,  however,  whether  the 
amputation  be  one  of  necessity  or  expediency,  is  an  additional  shock. 
Though  it  is  often  inevitable,  it  is  shock  created  by  the  procedure  of  the 
surgeon  himself.  For  this  reason  one  may  call  it  induced  shock,  and 
may  in  a  measure  take  means  both  before  and  during  the  operation  to 
prevent  it. 

This  induced  shock,  anesthesia  shock,  operation  shock,  or  whatever 
we  may  choose  to  call  it,  is  primaiy  shock,  always  in  the  case  of  amputa- 
tions of  expediency  (for  tumors,  deformities,  etc.) ;  but  in  the  case  of  all 
amputations  the  surgeon  must  anticipate  a  certain  amount  of  shock. 
We  prepare  for  the  contingency  of  shock  by  giving  morphin  and  atropin 
(morphin  sulphate,  gr.  l-{ ;  atropin  sulphate,  gr.  Tffij-eV)  •  We  employ 
an  anesthetic  with  discretion.  In  the  case  of  minor  amputations  and 
sometimes  in  the  case  of  major  amputations  even  we  may  make  use  of 
local  anesthesia.  In  certain  selected  cases,  especiall}'  when  the  patient 
is  old  and  a  sufferer  from  arteriosclerosis  or  renal  disease,  it  may  be 
well  to  use  for  anesthesia,  tropococain,  stovain,  and  strychnin  b}'  lumbar 
puncture.  As  a  rule,  however,  we  must  employ  a  general  anesthetic, 
and  of  the  general  anesthetics,  we  may  rely  upon  nitrous  oxid  and 
oxygen,  or  ether — alone  or  combined.  The  administration  of  the  anes- 
thetic should  always,  when  possible,  be  confided  to  a  skilled  anesthetist, 
who  should  use  the  least  possible  amount  of  the  drug.  Further  ex- 
pedients for  eliminating  shock  are  the  placing  of  the  patient  upon  a  hot- 
water  mattress  during  the  operation,  and  the  cocainizing  of  the  large 
nerve-trunks  before  cutting  them.  This  last  maneuver  (nerve  cocain- 
ization)  was  first  advocated  by  Crile  some  ten  years  ago,  and  has  met 
with  general  approval.  Expose  the  nerve  and  introduce  within  its 
sheath  by  a  hypodermic  needle  4  to  6  minims  of  a  4  per  cent,  cocain 
solution. 

Intimately  associated  with  the  question  of  shock  is  that  of  the  control 
of  hemorrhage — of  hemorrhage  which  leads  so  directly  to  an  increase, 
and  a  prolongation,  of  the  shock.  We  control  hemorrhage  by  producing 
a  general  ischemia  of  the  limb  to  be  operated  upon,  and  by  checking 
promptly  the  bleeding  vessels  in  the  wound  itself.  For  the  general 
ischemia  we  render  the  limb  as  bloodless  as  possible  by  elevating  it  for 
a  few  moments  before  operating,  and  by  applying  a  tourniquet.  Some 
operators  still  employ  the  Martin  i-ubber  bandage  to  squeeze  the  blood 
out  of  the  limb,  supplemented  by  the  rubber  tourniquet,  after  the 
method  of  Esmarch.  I  believe  that,  as  a  rule,  however,  this  use  of  the 
Martin  bandage  should  be  discountenanced ;  for  in  the  case  of  a  crushed 
limb,  the  bandage  may  give  rise  to  embolism;  while  in  the  case  of  an 


AMPUTATIOXS 


977 


infected  limb,  or  a  limb  the  site  of  malignant  disease,  it  is  possible  by 
the  rubber  bandage  to  force  the  products  of  disease  into  the  circulation. 
Elevate  the  limb,  therefore,  and  apply  a  tourniquet.  I  frequently 
employ  the  pneumatic  suit  also,  as  1  have  described  its  use  in  Chapter 
XX\'I1.  We  must  observe  a  further  precaution  in  the  use  of  the  famil- 
iar rubber  tourniquet.  If  we  draw  it  too  tight  or  leave  it  in  place  too 
long,  it  may  so  press  upon  the  underlying  nerves  as  to  cause  their 
degeneration,  with  a  subsequent  paralysis.  This  rarel}-  happens  in 
case  the  tourniquet  be  applied  to  the  thigh,  but  it  has  happened  fre- 
quently after  the  application  of  a  tourniquet  to  the  arm.     ^Yhen  the 


Fig.  663. — Esmarch's  elastic  bandage  and  tourniquet  tEsmarch'. 

arm  is  to  be  constricted,  therefore,  a  few  folds  of  towel  should  be  laid 
beneath  the  tourniquet,  and  the  tourniquet  itself  should  be  ribbon- 
shaped,  and  not  made  of  the  usual  elastic  tubing. 

The  molding  or  shaping  of  the  stump  has  become  a  matter  of  extreme 
interest  in  recent  years,  and  we  have  come  to  see  that  the  rapid,  old- 
fashioned  circular  amputations  often  leave  the  patient  with  a  stump 
poorly  adapted  for  the  wearing  of  an  artificial  limb.  The  treatment  of 
the  nerve-ends  so  as  to  avoid  subsequent  painful  neuromata  is  another 
important  desideratum.     The  old-fashioned  circular  amputation  was 


Fig.  664. — Circular  flap. 

made  by  turning  back  a  cuff  of  skin,  by  cutting  squarely  through  the 
limb  at  a  level  slightly  higher  than  the  cuff  level,  and  completing  the 
stump  by  drawing  down  and  stitching  the  cuff  immediately  below  the 
raw  surface.  This  method  of  amputating  is  rapid,  and  gives  us  a 
symmetric  and  seemly  stump.  Unfortunately,  however,  it  leaves  the 
end  of  the  stump  in  a  condition  easih'  subject  to  injur}-;  while  on  ac- 
count of  its  stiaicture  this  stump  may  become  extremely  painful.  Some 
six  years  ago  F.  T.  Murphy^  made  an  exliaustive  study  of  a  large  num- 
ber of  the  end-results  of  amputations  in  the  Massachusetts  General 

1  F.  T.  Murphy;  A  Study  of  Amputations  of  tlie  Lower  Extremity,  Boston  Med, 
and  Surg.  Jour.,  July  14,  1904. 

62 


978  MINOR   SURGERY — DISEASES   OF   STRUCTURE 

Hospital  clinic.     His  conclusions  are  valuable  and  are  worth  quoting 
here  in  full : 

''Anterior  and  posterior  muscle  flaps,  when  obtainable,  are  to  be 
preferred  to  the  circular  cuff  of  skin. 

"  The  fibula  should  be  cut  off  at  a  higher  level  than  the  tibia  in  leg 
amputations,  and  care  should  be  taken  to  bevel  off  bony  prominences, 
such  as  the  sharp  anterior  tibial  edge. 

"Suture  of  the  i^eriosteum  and  approximation  of  tlie  mu.scles  and 
fasciie  are  desirable. 

"  Drainage  of  the  stump  is  advised,  unless  the  dead  space  is  obliter- 
ated by  means  of  buried  sutures. 

"  Partial  amputations  of  the  foot  or  amputations  at  the  ankle-joint, 
except  under  unusual  conditions,  are  not  as  satisfactory  as  those  above 
the  ankle-joint. 

"  Tibial  stumps  between  6  and  S  inches  long  are  the  most  serviceable. 
"Amputations  through  the  knee-joint  are  inferior  to  those  just  above 
the  condyles. 

"The  longer  the  thigh  stump  the  better,  jjrovided  the  condyles  have 
been  removed. 

"  In  general,  in  tibial  amputations  down  to  4  inches,  and  in  thigh 
amputations  down  to  5  inches,  sacrifice  bone  in  order  tc  obtain  good 
muscle-flaps." 

These  observations  of  Mui'phy  are  sound,  and  while  his  studies 
embrace  amputations  of  the  lower  extremity  only,  the  general  tenor  of 
his  conclusions  is  applicable  to  the  upper  extremity  also.     Let  us  note 

one  exception,  however,  when  we  come  to 
a  consideration  of  arm  amputations ;  in  arm 
amputations  the  circular  cuff  method  is  often 
valuable,  while  it  rarely  leads  to  a  painful 
stump. 

In  regard  to  the  whole  subject  of  stumps, 
let  us  note  further  that  recent  studies,  notably 
those  of  Matas,  von  Mikulicz,  Gritti,  Bier, 
■oy,,  Hirsch,  Berger,  Kiister,  and  numerous  other 
FV  cc —P  -'i'  f  writers,  have  dealt  largely  with  the  treat- 
Une  oT sutures  by  the  ob-  ment  of  the  bone  itself.  There  is  a  general 
lique  incision  (Kocher).  agreement,  moreover,  that  muscle  flaps — ^not 

mere  skin-flaps — should  be  used;  that  the 
eventual  line  of  skin  suture  should  fall  behind  the  limb,  so  that  the  bone 
stumi?  may  not  press  upon  the  soft  cicatrix,  and  that  the  amputation 
should  be  made  w'ith  the  same  painstaking  care  as  that  employed  in 
amputating  a  breast  or  a  uterus.  The  old-time  hurried  slashing  is 
improper.  For  such  reasons  many  surgeons  have  abandoned  entirely 
the  ancient  amputating  knives,  and  cut  ofi"  the  leg  or  the  arm  with  an 
ordinary  scalpel,  much  as  they  would  cut  off  the  breast.  Neudorfer 
goes  still  further  and  abandons  the  saw  itself.  He  cuts  through  the 
bone  as  a  preliminary  step  in  his  operation,  employing  a  sharp  chisel 
or  a  Gigli  saw  (Fig.  666). 


AMPUTATIONS 


979 


The  question  of  whether  or  not  to  cover  the  bone  stump  with  peri- 
osteum is  still  (lebatetl.  Many  surgeons  beheve  that  a  proper  periosteal 
covering  promotes  prompt  bone-healing  and  a  painless  stump;  while 


Fig.  666. — Neudorfer's  method  of  amputation  by  primary  division  of  the  bone 
before  sliaping  the  flaps  (Matas). 

others,  especially  Hirsch,  have  contended  that  the  periosteal  covering 
is  unnecessary,  and  Bunge  maintains  that  the  periosteum  over  the  end  of 


A 


Fig.  667— Bier's  osteoplastic  amputation  of  the  leg:  A,  Showing  manner  of 
raising  an  osseoperiosteal  flap  from  tibia;  B,  showing  bone-flap  brought  oyer 
sawed  ends  of  tibia  and  fibula,  and  its  periosteal  margins  sutured  to  the  margins 
of  periosteum  around  tibia  and  fibula.  The  osseoperiosteal  flap  is  here  shown 
separated  from  its  soft  parts,  to  which  it  should  be  adherent.  (Bickham,  modified 
from  Bier.) 

the  bone  is  extremely  sensitive.  Bier,  on  the  other  hand,  prefers  an 
osteoplastic  method — a  covering  of  the  bone-end  with  a  transverse 
strip  of  new  bone  taken  from  higher  up  upon  the  shaft  (Fig.  667). 


980  MINOR  surgp:ry — diseases  of  structure 

My  own  conviction  and  practice  favor  the  use  of  periosteum  to  cover 
the  bone-end.  I  have  seen  no  special  value  in  Bier's  osteoplastic  flap. 
I  regtird  the  proper  treatment  of  the  muscles  and  the  skin-flap,  however, 
as  of  superlative  importance.  In  our  amputations  we  provitle  consider- 
able muscle-flaps,  which  can  be  drawn  over  the  bone-end,  and  we  lace 
them  together  with  buried  absorbable  stitches,  so  as  to  promote  prompt 
union,  a  perfect  hemostasis,  and  a  reasonably  shapel}-  stump.  In  an 
amputation  of  the  leg,  the  line  of  suture  should  fall  jiosteiior  to  the  bone- 
end,  as  Fig.  667  illustrates.^ 

Painful  Stump. — Neuralgia  of  the  stump  may  complicate  the  end- 
results  after  any  form  of  flap-  or  stump-molding.  Painful  stump  may 
be  due  obviously  to  a  badly  placed  cicatiix,  to  a  breaking  down  of  the 
scar  and  ulceration,  or  to  an  unduly  long  bone;  but  all  these  calamities 
are  avoidable  and  remediable  by  a  secondary  operation — shortening  the 
stump.  Thefe  is  one  form  of  painful  stump,  however,  the  cause  of  which 
is  much  more  deeply  seated — a  neuritis  or  growth  of  neuromata  on  the 
severed  nerve-ends.  These  neuromata  may  be  the  despair  of  surgeon 
and  patient  alike.  The  pain  is  often  excessive  and  extremely  wearing, 
so  that  the  patient's  life  becomes  almost  unbearable.  The  surgeon  opens 
down  upon  the  affected  nerves,  removes  the  neuromata,  and  resects  the 
nerves,  but  often  to  no  purpose;  the  pain  returns;  higher  resections  are 
made,  and,  finally,  in  desperation,  the  surgeon  may  remove  the  limb  en- 
tirely or  dissect  the  posterior  nerve-roots  of  the  cord.  These  are  radical 
procedures,  and  often  are  a  source  of  mortification  to  the  surgeon.  For 
the  last  four  years  I  have  been  following  the  practice  of  joining  to  each 
other  the  severed  nerve-ends  in  the  stump  itself — nerve  anastomosis — 

^  Theodor  Kocher,  in  his  Text-Book  of  Surgery,  second  English  edition,  p.  393, 
lays  down  the  following  interesting  rules,  which  correspond  with  the  conclusions 
we  have  drawn  in  the  text: 

"An  oblique  incision  (combined,  if  necessary,  with  a  longitudinal  one  in  the 
form  of  a  racket  or  lanceolate  incision)  through  skin  and  fascia.  After  retracting  tlie 
elastic  skin  the  muscles  are  divided  obhquely  down  to  the  bone.  The  periosteum 
is  also  to  be  divided  obhquely.  The  periosteum  is  then  separated  along  with 
the  superficial  layer  of  the  cortex  of  the  bone,  by  means  of  a  sharp  raspatory  or 
chisel,  or,  wlien  possible,  a  flap  of  bone  ha\'ing  a  movable  periosteal  hinge  is  made 
by  means  of  tlie  saw;  lastly,  if  only  a  thin  shell  of  the  cortex  lias  been  raised  up  along 
with  the  periosteum,  the  end  of  the  bone  is  simply  rounded  off,  wliile,  if  a  distinct 
flap  of  bone  (osteoplastic  method)  has  been  sawn  up,  the  end  of  the  bone  must  be 
sawn  in  a  curved  direction  so  as  to  fit  it. 

"The  periosteal  or  bony  flap  is  sutured  over  the  sawn  surface  of  the  bone  to  its 
periosteum.  The  stumps  of  the  muscles  or  tendons  are  sutured  to  each  other  or  to 
the  surface  of  the  bone  at  a  distance  from  the  sawn  surface.  Lastly,  the  skin  and 
fascia  are  sutured.  But  in  cases  where  a  periosteal  flap,  or  a  flap  of' bone  and  peri- 
osteum, cannot  be  obtained  in  a  normal  relation  to  the  other  soft  parts,  it  is  Ijetter 
to  remove  the  periosteum  entirely  from  the  end  of  the  stump,  to  scrape  out  the 
medullary  cavity  (accortling  to  Eiselberg  and  Bunge),  and  to  round  off  tlie  edges  of 
the  bone  as  dentists  do. 

"In  disarticulating,  care  for  the  shape  of  the  end  of  tlie  bone  is  unnecessary; 
the  upper  cartilaginous  surfaces  should  be  preserved,  as  they  are  insensitive  and  used 
to  pressure.  In  addition,  the  points  which  we  have  emphasized  in  excisions  are  to 
be  borne  in  mind,  viz.,  to  retain  the  attachments  of  the  tendons,  muscles,  and  liga- 
mentous capsule  to  the  cortical  layer  of  bone  subjacent  to  them.  In  other  words, 
the  subcapsular  method  is  to  be  added  to  wliat  we  have  just  described  as  the  normal, 
so  tliat  tlie  disarticulation  is  performed  by  what  may  be  termed  the  periosteo-plastic- 
subcortical  method." 


SPECIAL   AMPUTATIONS 


981 


with  the  purpose  of  securing  a  continuous  nei-ve  channel,  and  leaving 
no  nerve-ends  whatever  to  serve  as  the  seats  of  neuromata.  In  my 
list  of  23  cases  this  maneuver  has  proved  successful.  I  believe  we  are 
now  warranted  in  employing  it  in  all  major  amputations  as  a  preventive 
of  painful  stump. 

SPECIAL  AMPUTATIONS 

Amputation  of  the  Toes. — As  a  rule,  the  surgeon  should  not  ampu- 
tate through  the  phalanx  of  a  toe,  but  should  disarticulate  at  the  meta- 
tarsophalangeal joint.  The  racket-shaped  incision  is  the  best  incision, 
for  by  its  use  a  plantar  flap  may  be  turned  up  over  the  wound,  which 
is  thus  comfortably  protected.  After  making  the  flap,  the  surgeon 
sharply  flexes  the  toe  at  the  selected  point,  and  passes  his  knife  rapidly 


Fig.  668. — Disarticulation  of 
the  great  toe  at  the  metatarso- 
phalangeal joint,  and  of  the  sec- 
ond toe  along  with  its  metacarpal 
bone:  amputation  through  the 
third  toe  and  through  the  fifth 
metatarsal  bone  (Kocher). 


Fig.  669. — Disar- 
ticulation of  all  the 
toes  at  the  metatar- 
sophalangeal joints 
(Kocher) . 


Fig.  670. — Ampu- 
tation through  the 
metatarsus  (Kocher). 


through  the  joint  cavity,  remembering  that  he  must  enter  the  cavity 
at  a  point  the  bone's  breadth  beneath  the  knuckle.  There  are  usually 
two  terminal  arteries  to  be  tied.  Be  careful  not  to  include  nerve  twigs 
in  the  ligatures.  Do  not  sew  up  the  flaps  without  providing  for  drainage 
between  the  sutures.  Interrupted  sutures  are  best.  The  inevitable 
slight  leakage  behind  the  flaps  finds  its  way  between  the  sutures,  and 
if  the  wound  has  been  made  clean,  healing  is  prompt. 

In  the  case  of  amputations  of  the  great  toe  and  of  the  little  toe, 
make  the  cut  somewhat  toward  the  median  line  of  the  foot,  so  that 


982  MINOR    SIRGEHV-DISKASES    OF    STRUCTURE 

the  line  of  suture,  when  {•()ni])leted,  .shall  not  be  subject  to  laterul  pres- 
sure in  boot-weai'inii'. 

Partial  Amputations  of  the  Foot. — Ani])utali()ii,s  throujih  por- 
tions of  the  foot  have  been  modified  l)y  niany  surgeons,  and  various 
names  are  given  to  the  various  foot  amputations.  We  are  coming 
to  the  conclusion  that  most  of  these  amputations  through  the  bones 
of  the  foot  are  objectionable,  because  the  resulting  stumps  are  weak, 
inconvenient,  and  painful.  Total  removal  of  the  foot  (at  the  point  of 
election,  6  to  8  inches  below  the  tibial  tubercle)  gives  the  patient  a 
more  useful  limb.  The  amputations  through  the  foot  are  sometimes 
useful,  however,  their  designated  names  are  classic,  and  the  student 
should  be  familiar  with  their  nature. 

Lisfrancs  operation  is  a  disarticulation  of  all  the  toes  at  the  tarso- 
metatarsal joints — so  obvious  an  operation  that  the  .student  of  surgical 
history  wonders  why  an)''  one  man's  name  should  have  been  associated 
with  it.  Lisfranc's  operation  is  performed  with  a  short  dorsal  and  a 
long  plantar  flap — in  other  words,  the  .sole  of  the  foot  is  dissected  off 
and  turned  up  over  the  stump.  The  surgeon  seizes  the  toes  with  his 
left  hand  and  begins  his  incision  just  behind  the  base  of  the  fifth  meta- 
tarsal bone.  He  carries  the  cut  straight  along  the  outer  aspect  of  the 
foot  for  about  an  inch,  and  then  rounds  out  to  the  dorsum,  crossing 
the  foot  to  its  inner  edge,  and  carries  his  knife  back  so  as  to  complete 
the  flap  just  above  the  cuneiform  metatarsal  articulation  of  the  great 
toe,  somewhat  nearer  the  plantar  than  the  dorsal  aspect.  He  then 
forms  his  plantar  flap,  which  should  extend  nearly  to  the  tarsophalan- 
geal  joint.  The  surgeon  deepens  his  cuts,  retracts  his  flaps,  and  then 
firmly  extends  the  foot,  when  the  disarticulation  is  an  easy  matter. 
He  then  removes  the  tourniquet  and  picks  up  the  bleeding  vessels. 
I  believe  it  is  wise  to  drain  the  wound  with  a  rubber  wick  for  twenty- 
four  hours.  The  stump  should  be  put  up  in  a  large  elastic  compression 
dres.sing  reaching  to  the  knee.  The  foot  should  be  su])ported  on  a 
pillow,  or  slung  in  a  hammock  for  at  least  a  week,  when  healing  should 
be  sound  enough  to  permit  of  the  patient's  beginning  to  move  about 
on  crutches. 

Hey's  operation  is  similar  to  Lisfranc's,  except  that,  in  addition  to 
the  disarticulation  of  the  metatarsal  bones,  the  end  of  the  internal 
cuneiform  bone  is  sawed  off,  so  as  to  provide  a  smooth  and  even  bone 
stump. 

Chopart's  operation  is  a  disarticulation  of  the  anterior  part  of  the 
foot  at  the  mediotarsal  joint,  that  is  to  say,  the  astragaloscaphoid 
joint  and  the  calcaneocuboid  joint.  The  operation  provides  flaps 
similar  to  the  Lisfranc  flaps,  except  that  they  are  made  somewhat 
longer  and  are  started  opposite  the  calcaneocuboid  joint. 

Syme's  operation — disarticulation  of  the  foot  at  the  ankle-joint. 
Syme's  operation  pre.serves  the  plantar  surface  and  the  soft  parts  of 
the  tip  of  the  heel,  which  is  made  to  cover  the  lower  ends  of  the  tibia 
and  fibula,  whose  malleoli  are  removed.  The  surgeon  makes  his  incision 
directly  down  to  the  bone  from  the  tip  of  one  malleolus  across  the  sole 


SPECIAL    AMPUTATIONS 


983 


and  up  to  the  other.  lie  then  forces  the  foot  into  extreme  phintar 
ilexion,  and  carries  a  second  incision  directly  across  the  dorsum,  thus 
joining  the  two  entls  of  the  first  incision.  He  then  opens  the  ankle- 
joint  in  front;  divides  the  lateral  ligaments  and  disarticulates  the 
astragalus  forward.  Next  he  separates  the  soft  parts  of  the  heel  from 
the  OS  calcis,  which  he  removes.  He  has  now  left  the  articulating 
ends  of  the  tibia  and  fibula.  He  saws  off  the  malleoli  and  turns  the 
heel-flap  up  over  the  stump. 

Pirogoff's  operation — disarticulation  of  the  foot  at  the  ankle-joint, 
with  removal  of  the  malleoli,  the  articular  surface  of  the  tibia,  and  the 
anterior  part  of  the  os  calcis.     As  Kocher  remarks,  Pirogoff's  operation 


Fig.  671 . — Plantar  incisions :  A,  Lis- 
franc;  B,  Chopart;  C,  Pirogoff;  D, 
Syme;  E,  Farabeuf's  subastragaloid 
amputation;  F,  Farabeuf's  amputation 
at  the  ankle  (Dennis). 


Fig.  672. — Pirogoff's  amputation: 
Appearance  of  the  parts  after  removal 
of  the  malleoli  (Erichsen). 


derives  its  importance  from  the  fact  that  it  was  the  first  osteoplastic 
operation  introduced.     It  dates  from  1854. 

Pirogoff's  operation  resembles  Syme's  in  many  of  its  features.  The 
Syme  incision  is  employed,  and  all  the  bones  of  the  foot  are  removed 
except  the  posterior  portion  of  the  os  calcis.  This  slip  of  bone  is  shaped 
by  the  use  of  a  small  saw  as  indicated  in  the  cut.  It  is  well  to  begin 
Pirogoff's  operation  by  a  tenotomy  of  the  tendo  Achillis,  thus  allowing 
the  heel-bone  readily  to  be  drawn  up  and  implanted  upon  the  stumps 
of  the  tibia  and  fibula.  The  Pirogoff  stump  is  fairly  useful,  and  is  more 
satisfactory  than  that  of  Syme. 

Amputations  of  the  Leg.— The  subject  of  leg  amputations  has  been 
one  of  no  little  controversy,  the  matters  in  dispute  being  particularly— 


984 


MINOR    SUPGEHY— DISEASES    OF    STHUCTUKE 


(1)  The  best  point  at  -which  to  amputate;  and  (2)  the  method  of 
amputation.  Surgeons  are  now  agreed  that  amputations  should  be 
made  as  low  as  possible  consistent  with  the  production  of  a  stump 
capable  of  bearing  an  artificial  leg.  So  we  have  coined  the  term  "point 
of  election,"  by  which  we  mean  a  point  on  the  tibia  about  eight  inches 
below  the  tibial  tubercle.  Amputations  above  this  point  are  not  of 
election,  so  that  the  nearer  we  come  to  the  point  of  election,  the  more 
satisfactoiy  will  be  our  results.  In  the  lower  and  middle  thiids  of 
the  leg  the  bulk  of  the  muscles  is  posterior;  when  we  operate  in  this 
region,  therefore,  we  find  that  a  posterior  flap  gives  the  best  covering 
for  the  stump.  ^^  hen  we  operate  in  the  upper  third  of  the  leg,  where 
the  bulk  of  the  muscles  is  postero-external,  we  aim  to  secure  a  flap 
chiefly  external.     Whatever  flap  be  made,  we  should  cut  the  fibula 


Fig.  673. — Cross-section  of  lower  third  of  the  right  leg  (adapted  from 

Bickham). 


slightly  higher  than  the  tibia,  as  the  fibula  in  the  stump  is  easily  drawn 
out  of  position  and  exposed  to  pressure.  In  sawing  through  the  bones 
of  the  leg  we  should  be  careful  to  bevel  the  anterior  edge  of  the  tibia 
before  making  the  transverse  cut.  There  is  little  difficulty  usually  in 
finding  the  arteries  and  controlling  hemorrhage  from  a  leg  stump.  The 
important  arteries  are  the  anterior  tibial,  the  posterior  tibial,  and  the 
perineal,  whose  positions  are  shown  in  the  illustration  taken  from 
Bickham's  Operative  Surgery. 

We  need  not  here  consider  the  great  variety  of  .special  amputations 
which  have  been  devised  for  special  conditions,  but  we  may  suggest, 
by  means  of  the  illustrations  in  the  text,  the  nature  of  the  various 
incisions  which  we  recommend. 

For  amputations  at  the  point  of  election,  if  we  discard  the  old-time 


Sl'ECIAL   AMPUTATIONS 


985 


cuff  method,  we  shall  do  well  to  follow  the  line  of  Stephen  Smith's 
operation,  and  tiu'n  up  a  long  posteiior  flap,  observing  that  the  cut 
through  the  bones  is  made  at  the  highest  point  attainable  above  the 
base  of  the  flap. 

•  In  making  these  leg  amputations  the  surgeon  should  have  in  mind 
and  should  follow  a  proper  routine  if  he  is  to  have  his  operation  come 
off  smoothly  and  easily.     The  patient  should  be  drawn  well  over  the 
end  of  the  operating  table;   the  sound  leg 
should  be  tied  down   out   of  the  way,   and 
an  assistant  should  hold  the  foot  to  be  am- 
putated in  a  somew^hat  elevated  position  in 
order  that  the  surgeon  may  have  every  part 
of  the  leg   circumference  well  within   the 
sweep  of  his  knife.     He  may  make  a  large 
skin-and-muscle    flap    by    transfixion    and 
cutting  outward  with  the  long  amputating 
knife;  or  he  may  dissect  a  skin-flap  back 
carefully  with  a  scalpel.     After  he  has  com- 
pleted his  flaps,  he   may  employ  the  old- 
time  Catlin  in  order  to  clean  away  the  inter- 
osseous tissue,  or  he  may  dissect  this  tissue 
away  with  a  scalpel.     My  own  preference 
is  to  use  a  small  knife  through  most  of  the 
operation,  for  with    the    small   knife    one 
works  more  accurately  and  may  quickly  ex- 
pose the  bone-ends,  from  which  periosteum 
is  to  be  stripped  back  before  the  bones  are 
sawed.     Having  turned  back  the  periosteum 
and  the  soft  parts,  and  having  sawed  through 
the  bones,  the  surgeon  searches  at  once  for 
the  important  arteries  with  their  veins,  and 
ties   them  all;    he   has  the   tourniquet  re- 
moved;  he  picks  up  with  catch  forceps  all 
the    smaller    bleeding   points,   and    checks 
entirely  all  hemorrhage,  tying  the  vessels 
with  silk  or  plain  catgut,  according  to  his 
convictions  regarding  ligature  material;  he 
draws  out  the  nerve-ends  and  stitches  them 
accurately  together  end  to  end.     He  then 
completes  the  hemostasis,  if  that  be  needed, 
and  molds  the  stump  by  careful  suturing 
and  lacing  of  the  muscles  across  the  bone-end.     Finally,  he  brings  the 
skin-flap  accurately  into  place.     Some  redundancy  of  skin-flap  is  an 
advantage  rather  than  the  reverse.     If  the  hemostasis  be  absolute, 
drainage  wicks  are  unnecessary,  but,  as  a  rule,  it  is  well  to  drain  the 
stump  for  twenty-four  hours  at  least.     At  the  time  of  the  operation 
the  surgeon  may  deem  all  hemorrhage  checked,  but  later,  when  the 
patient  has  been  put  to  bed,  when  shock  has  subsided,  and  when  the 


Fig.  674. — Amputation  of 
leg:  A,  Modified  circular;  B, 
rectangular  flaps;  C,  antero- 
posterior flaps,  upper  tliird. 


986  MINOR    SUHGEIIY — DISEASES    OF    STIUTTl-RE 

arterial  circulation  again  has  become  vigorous,  a  secondary  oozing  into 
the  stump  is  common.  The  leg  should  be  tlressed  in  an  abundant  ab- 
sorbent dressing,  reaching  well  above  the  knee,  and  the  whole  liiiih 
should  be  carefully  immoljilizcd  ui^on  a  comfortable  s])lint. 

Many  surgeons  prefer  the  Teale  metiiod  of  aminitation.  The  Teale 
method  is  that  of  providing  a  long  anterior  flap.  The  resulting  stump 
is  seemly  and  useful,  while  the  operation  is  somewhat  easier  than  that  I 
have  just  described. 

Amputations  through  the  middle  of  the  calf  are  perfoi-med  on  much 
the  same  plan,  for  the  arrangement  of  the  parts  does  not  differ  materially 
from  their  arrangement  in  the  lower  third  of  the  leg. 

When  we  come  to  amputations  in  the  upper  third  of  the  leg,  or  im- 
mediately below  the  knee,  we  have  to  consider  the  possibility  of  adapt- 
ing the  short  stump  to  an  artificial  leg.  Many  surgeons  believe  that 
we  should  never  make  a  tibial  stump  less  than  four  inches  long,  but 
that  the  surgeon  should  perform  his  amputation  by  disarticulating 
the  knee-joint,  or  by  amputating  above  the  femoral  condyles.     I  have 


Fig.  67.5. — Teale 's  amputation. 

fovmd,  however,  that  a  short  tibial  stump,  which  is  often  troublesome 
on  account  of  the  back  pull  of  the  hamstring  muscles,  can  be  made 
useful  if  we  perform  a  tenotomy  on  the  hamstrings. 

Many  surgeons  still  amputate  through  the  knee-joint.  At  the 
Massachusetts  General  Hospital  we  rarely  ])erform  this  operation,  as 
we  are  convinced  that  amputation  above  the  condyles  of  the  femur 
gives  the  patient  a  more  useful  stump. 

Should  the  surgeon  think  it  wise,  however,  to  perform  knee-joint 
disarticulation,  he  may  well  follow  the  commonly  adopted  bilateral 
method  of  Stephen  Smith.  Begin  the  incision  one  inch  below  the  tubercle 
of  the  tibia,  and  carry  it  downward  and  foi-ward  around  the  side  of  the 
leg  and  so  up  into  the  popliteal  space,  making  a  lateral  flap.  Duplicate 
this  flap  on  the  other  side.  Separate  the  soft  parts  from  the  bone; 
divide  the  joint  ligaments  and  remove  the  leg  with  the  patella.  Some 
observers  maintain  that  this  disarticulation  causes  less  shock  than 
does  a  regular  amputation.  Be  that  as  it  nux}',  we  secure  a  far  better 
stump  by  supracondyloid  amputation. 


SPECIAL    AMPUTATIONS 


9S; 


Supracondyloid  Amputation.— Frohixhly  the  best  method  for  this 
operation  is  that  suggested  by  Stokes  and  Gritti,  which  consists  of 
section  of  the  femur  above  the  condyles  with  an  osteoplastic  flap, 
formed  by  the  split  patella.  The  authors  point  out  that  by  this  means 
the.  strong  anterior  weight-bearing  patellar  sui'face  becomes  the  end 
of  the  stump. 

As  we  approach  the  hip-joint  in  our  amputations,  the  danger  of 
shock  increases,  coincident  with  a  rise  in  the  operative  mortality. 
For  such  reasons  surgeons  should  amputate  the  thigh  with  great  care 
and  forethought,  using  every  means  to  minimize  shock  and  hemor- 
i-l^j^ge— especially  by  elevation  of  the  leg;  by  careful  application  of  the 
tourniquet;     by   perfect  hemostasis,    and   by  nerve    cocainization.     I 


Ti£ 


676-Wyeth's  hip-joint  amputation:    Pins  and  rubber  tube  tourniquet   in 
position.     The  Esmarch  bandage  has  been  removed  (Wyeth). 

prefer  long  muscle-flaps  when  they  are  available,  and  a  thorough  lacing 
together  of  the  flaps  in  completing  the  suturing  of  the  stump.  _   In 
mid-thigh  amputations  the  surgeon  has  to  find  and  secure  especially 
the  femoral  and  popliteal  arteries,  while  he  must  take  pams  to_  treat 
the  sciatic  and  anterior  crural  nerve-ends  by  a  proper  anastomosis. 

The  hip-joint  amputation  has  always  been  a  matter  of  keen  interest 
to  surgeons  since  amputations  at  the  hip-joint  have  been  done, 
for  the  operation  is  a  relatively  modern  one.^  The  shock  is  often 
extreme,  and  the  hemorrhage  not  always  easy  to  control,  while  death 
from  complications  may  follow  unexpectedly.     Not  long  ago  I  had 

1  Walter  Brashear,  at  Bardstown,  Kentucky,  in  August,  1806,  performed  the 
first  successful  amputation  at  the  hip-joint. 


988  MINOR    SURGEin' — DISEASES    OF    STIU'CTURE 

occasion  to  amputate  at  the  hip-joint  for  Harconia  of  the  thi<ili  in  an 
apparently  vigorous  young  man.  The  operation  went  off  satisfactorily, 
but  unfortunately  the  patient  never  rallied  and  died  in  about  two 
hours.  An  autopsy  revealed  the  fact  that  he  was  a  victim  of  status 
lymj^haticus,  so  that  I  found  what  consolation  I  could  in  the  probability 
that  he  would  have  died  from  any  minor  operation. 

In  hip-joint  amputations,  or,  more  properly,  in  hip-joint  di.sai-ticula- 
tions,  for  the  operation  always  involves  disarticulation,  one  must  guard 
especially  against  hemorrhage.  With  a  view  to  minimizing  hemorrhage, 
various  methods  of  operating  have  been  devised,  and  the  operation  of 
John  A.  AA'veth  has  found  a  just  popularity.  For  myself,  I  have  always 
been  satisfied  with  an  amputation  preceded  by  a  preliminary  ligation 


Fig.  677. — Same  as  Fig.  676,  showing  the  soft  parts  dissected  from  the  bone  and 
the  capsule  exposed  (Wyeth ) . 

of  the  femoral  artery  at  Poupart's  ligament,  the  turning  back  of  large 
anterior  and  posterior  flaps,  and  the  careful  dissecting  away  of  the  bone, 
taking  up  the  smaller  severed  vessels  as  one  takes  up  vessels  in  a  breast, 
amputation.  I  then  cocainize  the  anterior  crural  and  sciatic  nerves 
and  join  them  by  the  usual  anastomosis. 

Wyeth's  Method. — In  his  admirable  essay  on  disarticulation  at  the 
hip-joint,  Wyeth  reminds  us  of  Avshhurst's  writing  in  1881:  ''The 
removal  of  the  lower  limb  at  the  coxofemoral  articulation  may  be  pro- 
perly regarded  as  the  gravest  operation  that  the  surgeon  is  ever  called 
upon  to  perform,  and  it  is  only  within  a  comparatively  recent  period 
that  it  has  been  accepted  as  a  justifiable  procedure.  The  most  pressing 
risk  is  that  of  hemorrhage." 


SPECIAL    AMPUTATIONS  989 

The  notable  feature  in  Wyeth's  operation  is  hiw  method  of  control- 
ling hemorrhage  by  pins  and  a  rubber  tourniquet,  which  render  the 
procedure  nearly  bloodless.  As  that  surgeon  writes,  the  limb  to  be 
amputated  shovdd  be  emptied  of  blood  so  far  as  possible,  and  while  the 
leg  is  elevated,  the  tourniquet  is  applied:  ''The  object  of  this  constric- 
tion is  the  absolute  occlusion  of  eveiy  vessel  above  the  level  of  the  hip- 
joint.  .  .  To  prevent  any  possibility  of  the  tourniquet  slipping, 
I  employ  two  large  steel  needles  or  skewers,  x«-  of  an  inch  in  diameter 
and  10  inches  long,  one  of  which  is  introduced  |  of  an  inch  below  the 
anterior-superior  spine  of  the  ilium  and  slightly  to  the  inner  side  of 
this  prominence,  and  is  made  to  traverse  superficially  for  about  3 
inches  the  muscles  and  fascia  on  the  outer  side  of  the  hip.  .  .  .  The 
point  of  the  second  needle  is  thrust  through  the  skin  and  tendon  of 
origin  of  the  adductus  longus  muscle  half  an  inch  blow  the  crotch,  the 
point  emerging  an  inch  blow  the  tuber  ischii.  The  points  should  be 
shielded  at  once  with  a  cork  to  prevent  injury  to  the  hands  of  the  opera- 
tor. No  vessels  are  endangered  by  these  skewers.  A  mat  or  com.press 
of  sterile  gauze,  about  2  inches  thick  and  4  inches  square,  is  laid  over 
the  femoral  artery  and  vein  as  they  cross  the  brim  of  the  pelvis;  over 
this  a  piece  of  strong  white  mbber  tubing,  half  an  inch  in  diameter 
when  unstretched,  and  long  enough  when  in  position  to  go  five  or  six 
times  around  the  thigh,  is  now  wound  veiy  tightly  around  and  above 
the  fixation  needles,  and  tied." 

As  to  the  further  conduct  of  the  operation,  Wyeth  allows  himself 
to  be  guided  by  the  condition  of  the  patient.  When  permissible,  he 
employs  a  modified  racquet  incision;  turns  back  a  cuff;  divides  the 
soft  parts  transversely  to  the  bone;  disarticulates,  and  finally  secures 
the  vessels.  He  then  completes  the  hemostasis  and  suturing  in  the 
usual  manner. 

We  see  that  by  employing  Wyeth's  method  we  eliminate  hemorrhage. 
If  the  patient  survive  the  primary  shock,  he  should  recover  promptly 
with  sound  and  satisfactory  wound  healing. 

Amputations  of  the  Upper  Extremity. — All  amputations  from  the 
fingers  to  the  thorax  are  interesting — more  interesting  perhaps  than  the 
corresponding  amputations  of  the  lower  extremity.  The  lower  ex- 
tremity is  concerned  mainly  in  strong  and  coarse  movements,  so  that  it 
endures  a  good  deal  of  mutilation  without  serious  loss  of  function; 
but  the  upper  extremity  is  concerned  largely  with  delicate  and  finely 
coordinated  movements,  such  as  writing,  sewing,  and  work  in  the 
mechanical  arts.  For  such  reasons  we  must  be  chary  of  mutilating 
the  hand  and  aim,  and  must  retain,  so  far  as  possible,  every  structure 
in  its  normal  relations.  The  fingers  especially  must  be  treated  with  the 
most  respectful  consideration ;  every  possible  fraction  of  an  inch  must  be 
saved,  and  the  tips  of  the  stump  must  be  made  tactile  and  prehensile. 

In  operating  upon  the  fingers  and  hands,  it  has  become  customary 
in  dispensary  clinics  to  use  cocain  anesthesia.  My  experience  has  led 
me  gradually  to  the  conviction  that  cocain  is  not  alwaj^s  the  best  anes- 
thetic for  these  delicate  operations,  but  that  frequently  sensitive  patients 


9d0 


MIXUlt    SUl{Cii:UY — DISEASES    (JF    STllUCTURE 


with  more  or  less  intricate  lesions  had  best  be  given  a  general  anes- 
thetic. 

We  approach — the  joint  if  we  are  to  disai-ticulate,  or  the  phalan- 
geal shaft  if  we  are  to  amputate — by  an  incision  which  leaves  a 
long  anterior  flap — the  tactile  palmar  surface.  In  disarticulating 
it   is  not    well    to   leave  the  synovial    joint   surface   as   a   finger-tip. 


Fig.    678.  —Removal    of    index-finger 
( Erichsen  i . 


Fig.    679. — Removal   of    little    finger 
( Erichsen). 


Fig.  680. — Results    of    amputation  Fig.  681.  -Hand  after   removal    of 

above    metacarpophalangeal    articula-  metacarpal    bones   and    three   fingers, 

tion  (Erichsen).  leaving  thumb  and  Uttle  finger  (Erich- 

senj. 

It  is  better  to  scrape  or  trim  off  the  synovial  membrane,  which  is 
a  structure  of  low  vitality  and  subject  to  infection  and  necrosis,  which 
may  cause  tedious  wound  healing.  The  thumb  is  best  removed  at 
an  articulation  by  a  single  palmar  flap  without  the  preservation  of 
the  sesamoids,  which  belong  to  its  short  flexor.  The  figures  in  the  text, 
taken  from  Roswell  Park's  Modern  Surgery,  illustrate  the  various 
flaps  employed.     That  writer  reminds  us  of  the  useful  suggestion  of 


SPECIAL    AMI'LTATIONS  991 

Lauenstcin;  when  the  first  three  fingers  are  to  be  removed,  leaving  only 
the  thumb  and  Uttle  finger,  he  makes  a  small,  pi'operly  placed  incision 
with  cutting  forceps,  which  divides  the  metacarpal  bones  of  the  thuml) 
and  Httle  finger  at  about  the  middle,  and  then,  by  giving  these  meta- 
carpals a  little  twist  toward  each  other,  he  produces  a  two-fingered 
claw,  which  is  capable  of  grasping  objects  strongly. 

We  were  formerl}'  taught  that  when  a  single  finger  is  amputated, 
its  metacarpal  bone  had  best  be  taken  with  it,  as  thus  a  more  sightly 
hand  is  produced.  I  doubt  this.  It  is  a  matter  of  taste.  Certainly 
the  hand  of  a  laboring  man  is  greatly  weakened  by  the  removal  of  one 
of  his  metacarpals.  The  wounds  of  finger  amputations  heal  rapidly 
if  not  infected.  Ten  days  after  amputation  a  finger  stump  should  be 
comfortable  and  even  useful. 

Hand  Amputations  and  Wrist  Disarticulations. — Although  an  arm 
without  a  hand  may  seem  more  useless  than  a  leg  without  a  foot,  we  _ 
must  not  think  of  such  an  arm  as  a  contemptible  member.  Artificial 
hands  may  be  fitted  to  arm-stumps  for  cosmetic  reasons;  but  such 
artificial  hands  are  of  no  practical  service.  After  all  is  said,  the  stout 
old-fashioned  hook,  for  general  purposes,  is  the  most  useful  substitute 
for  a  hand. 

Disarticulations  of  the  hand  may  be  made  below  or  above  the  carpus ; 
indeed,  it  makes  little  difference  at  which  level  we  disarticulate.  The 
form  of  flap  is  of  some  importance,  however,  for  the  tough  palmar  skin 
of  the  hand  drawn  over  the  stump  gives  us  a  member  somewhat  more 
useful  than  one  furnished  with  delicate  dorsal  skin. 

Amputations  through  the  forearm  call  for  no  special  mention  except 
reminding  the  reader  that  carefully  executed  cuff  amputations  give 
suitable  stumps. 

Disarticulation  through  the  elbow-joint  is  sometimes  useful,  and 
is  not  open  to  the  same  objection  as  is  disarticulation  through  the  knee- 
joint.  The  major  portion  of  the  flap  to  cover  in  the  elbow  should  be 
taken  from  the  front  of  the  arm  and  the  scar  should  be  made  to  He  behin d 
the  humenis. 

Above  the  elbow  the  arm  furnishes  no  points  of  special  interest 
in  amputations.  The  circular  cuff  is  of  service,  or  the  rapid  transfixion 
method  with  long  muscle-flaps  may  be  employed.  In  either  case,  and, 
indeed,  in  all  amputations,  we  must  bear  in  mind  the  frequency  of  stump 
neuromata,  and  must  treat  our  nerve-ends  accordingly  by  anastomosis. 

The  shotdder-joint  amputation,  or  disarticulation  at  the  shoulder,  is 
similar  in  many  respects  to  disarticulation  at  the  hip,  and  in  a  minoi' 
degree  its  dangers  are  the  same — hemorrhage  and  shock.  Many  sur- 
geons control  the  hemorrhage  by  the  use  of  wire  pins.  I  have  dis- 
articulated at  the  shoulder-joint  many  times  without  them,  and  in- 
variably have  tied  the  subclavian  as  a  preliminary  step.  ^  Perhaps  I 
have  followed  this  method  from  habit  or  fancy.  Certain  it  is,  I  believe, 
that  Wyeth's  method  with  pins  is  most  generally  applicable. 

We  may  make  an  incision  of  the  racquet  form,  starting  from  the 
acromion  process  and  carrying  the  cut  down  to  and  around  the  arm; 


992  MINOR    SLRGIORY-    DISEASES    OF    STRUCTURE 

or  we  mayuHC  the  doiil)le  flap  method — tuining  up  first  the  whole  del- 
toid; disarticulcitiiig  the  humerus;  then  seizing  the  vessels  in  the  axilla 
and  completing  the  interior  or  axillary  flap. 

Removal  of  the  Whole  Upper  Extremity. — This  is  known  as  the  inter- 
scapulothoracic^  amputation,  and  is  gradually  coming  into  favor  with 
progressive  surgeons.  Its  sole  purpose  pi-actically  is  for  the  removal  of 
extensive  malignant  disease  of  the  arm  and  shoulder.  As  Cobb  points 
out,  the  important  points  in  the  operation  are  the  control  of  hemorrhage, 
and  the  prevention  of  shock  when  dividing  the  gi-eat  nerve-trunks. 
Death  from  the  operation  is  usually  from  shock,  with  or  without  hem- 
orrhage. In  these  eat;es.  as  in  disarticulation  at  the  hip-joint,  surgeons 
have  found  the  coeainizalion  of  the  nerve-trunks  before  dividing  them 
to  be  of  great  value. 

There  is  little  divergence  of  opinion  among  surgeons  rcganling  the 

,  technic  of  this  operation,  the  one  important  point  of  debate  being  as 

to  the  removal  of  the  whole  or  a  part  of  the  clavicle.     I  prefer  sawing 

through  the  clavicle  at  its  middle  third,  and  leaving  its  sternal  portion,  as 

I  am  convinced  that  its  total  removal  adds  to  the  shock  of  the  operation. 

The  steps  of  the  operation  are  as  follows:  Cut  down  upon  and  secure 
the  subclavian  vessels  at  their  middle  third,  and  divide  the  clavicle 
at  this  point.  Cut  the  subclavian  vessels  between  the  ligatures,  the 
artery  first  and  later  the  vein,  after  the  arm  has  been  emptied  of  blood 
by  elevation.  The  steps  to  this  point  are  preliminary.  Now  comes  the 
actual  amputation.  The  incision  is  continued  from  the  point  over  the 
divided  vessels  and  curved  downward  to  the  anterior  axillary  fold.  The 
clavicular  portion  of  the  pectoralis  major  is  separated  with  the  finger 
from  the  costal  portion  of  the  muscle  up  to  the  anterior  axillary  fold; 
the  clavicle  is  pulled  down,  the  subclavians  stripped  off,  and  the  pec- 
toralis minor  is  divided,  when  the  whole  axilla  is  found  to  be  fully 
exposed.  At  this  point  the  surgeon  should  cocainize  the  nerves  of  the 
brachial  plexus,  and  sweep  the  axilla,  cleaning  up  nerves  and  vessels. 

The  next  step  is  to  carry  the  posterior  incision  from  the  original 
cut  backward  and  downward  to  the  inferior  angle  of  the  scapula,  and 
then  up  to  meet  the  anterior  incision.  Dissect  back  the  skin  and  fascia; 
divide  the  trapezius,  and  secure  bleeding  points;  divide  the  omohyoid 
muscle,  and  in  succession  the  remaining  muscles  attached  to  the  scapula. 
This  completes  the  operation  practically,  for  the  upper  extremity 
may  now  be  lifted  out.  Should  the  growth  for  which  the  operation  is 
undertaken  make  necessarj^  an  irregular  dissection,  skin  to  close  in  the 
open  space  may  be  secured  from  the  inner  aspect  of  the  arm.  Usually 
the  skin-flaps  come  together  nicely,  when  with  abundant  dressing  and 
careful  bandaging  a  comfortable  wound  results.  The  mortality  from 
this  operation  is  not  low,  for  patients  who  come  to  it  are  generally  debili- 
tated from  long-standing  disease.  The  resulting  mutilation  is  great. 
Few  persons  realize  the  peculiar  conic  shape  imparted  to  the  upper  por- 
tion of  the  thorax  by  the  removal  of  the  whole  upper  extremitv. 

^  Admirable  reports  of  this  operation  have  been  published  by  Robert  G.  LeConte, 
Ann.  Surg.,  October,  1902,  and  by  Farrar  Cobb,  ibid.,  February,  1905. 


INDEX 


Abbe,  Robert,  119,  705 
Abdomen,  contusions  of,  251 

pendulous,  253 

penetrating  wounds  of,  55 
Abdominal  aorta,  ligation  of,  780 

belts,  62 

drainage,  232 

hernia,  192 

hysterectomy  for  cancer,  315 

pregnancy,  341 

ptosis,  166,  243 

wall,  diseases  of,  251 
tumors  of,  252 
Abernethy,  John,  737 
Aberrant  goiter,  611 
Abscess,  alveolar,  559 

bone,  948 

brain,  653 

breast,  529 

cerebral,  652 

"cold,"  949 

deep  cervical,  594 

ischiorectal,  95,  96 

liver,  156 

lung,  484 

of  spleen,  188 

palmar,  745,  749 

Brooks'  incision  for,  751 

paranephritic,  379 

paraurethral,  452 

sub-diaphragmatic,  131 

tongue,  571 

tubo-ovarian,  322 
Absorbent  tape,  733 
Accessory  thyroids,  598 
Acromegaly,  657,  954 
Actinomycosis,  69,  70 

of  breast,  531 

of  esophagus,  127 

of  intestines,  69 

pulmonaiy,  486,  504 
Adami,  819 
Addison's  disease,  600 
Adenia,  799 
Adenitis,  798 

cervical,  589 

tuberculous,  treatment  of,  591 
Adenocarcinoma  of  breast,  511 

of  uterus,  306 
Adenoid  disease,  799 
Adenoids,  577 
Adenolymphoma,  799 
Adenoma,  840 

of  testicle,  476 

63 


Adhesions,  gastric,  144 

Aitken,  H.  F.,  346,  347,  348,  349,  350 

Akbarran,  363 

Albert,  189 

Alexander,  Samuel,  427 

operation,  277,  278,  279 
Allen,  Dudley  P.,  594,  663 
AUingham,  100 
Allis,  O.  H.,  935,  937 
Alveolar  abscess,  559 

process,  cyst  of,  561 
American  Medical  Association,  35 
Ampulla  of  Vater,  178,  182 
Amputation,  974 

immediate,  975 

neuromata,  709 

of  breast,  Warren's  operation,  516 

of  foot,  982 

of  hand,  991 

of  hip-joint,  987 

of  penis,  451 

of  shoulder-joint,  991 

of  toes,  981 

of  upper  extremity,  989 

primary,  975 

secondary,  975 

Teale's,  986 
Anal  resection,  109 
Anastomosis,  accessory,  576 

end-to-end,  54 

lateral,  68 

nerve,  711 
in  stump,  710 

spino-facial,  711 
Anders,  92 

Anel,  operation  of,  786 
Anel's  method,  791 
Anemia,  splenic,  190,  799 
Aneuiysm,  783 

cirsoid,  556,  557,  618,  V76 

of  hepatic  artery,  167 

of  innominate  artery,  785 

treatment  of,  786 

varicose,  776 
Aneurysmal  varix,  776,  784,  791 
Aneurysmorrhaphy,  790 
Angioriia,  99,  556,  776,  837 

plexiform,  776 
Angiosarcoma,  835 
Ankle-joint,  excision  of,  969 
Ankyloglossia,  570 
Ankylosis  of  jaws,  560,  561 
Ano,  fistula  in,  97 
operation  for,  99 

993 


994 


INDEX 


Anteflexion  of  uterus,  285 
Anterior  tibial  artery,  782 
Anteversion  of  uterus,  276,  284 
Antrum,  emi)yeraa  of,  5G0 
Antyllus,  772 

operation  of,  780 
A.nus,  aitifieial,  52,  82,  83,  84,  92,  111 
Kocher's,  86 

cancer  of,  106 

fissvue  of,  94 

imperforate,  90,  91 

prolajjse  of,  102 

syphilitic  affections  of,  94 

tuberculosis  of,  94 

tumors  of,  10;") 
Aorta,  ligation  of  abdominal,  780 
Apoplexy,  629 

pancreatic,  183 
Appendectomy,  Battle's  method  of,  32 

early,  32 

McBumey's  method  of,  32 
Appendiceal  colic,  22 
Ajipendicitis,  17 

acute,  22 

chronic,  22,  25,  26,  29,  30,  40,  54 

diagnosis  of,  31 

etiology  of,  20 

forms  of,  23 

gangrenous,  22 

in  children,  25 

pathology  of,  22 

prognosis  of,  31 

relapsing,  22,  25,  29,  40 

simulated,  25,  59 

symptoms  of,  26 

treatment  of,  31 

with  peri-appendicular  involvement,  28 
Appendicostomy,  64 
Appendix,  vermiform,  anatomy  of,  17 
catarrh  of,  22 
function  of,  20 
hydrops  of,  22 
segmented,  24 
stump,  treatment  of,  40 
Arachnoid,  643 

Aran's  theory  of  irradiation,  622 
Arteries,  ligation  of,  776 
Arteriorrhaphy,  792 
Arter^',  anterior  tibial,  782 

axillaiy,  779 

brachial,  780 

cystic,  177 

facial,  779 

femoral,  780 

hepatic,  aneurysm  of,  167 

innominate,  777 
aneuiysm  of,  785 

lingual,  779 

posterior  tibial,  780 

radial,  780 

superior  hemorrhoidal,  780 
Arthrectomy,  964 
Arthritis,  chronic,  957 
Ashhurst,  64 
Asphyxia,  traumatic,  502 
Astrag-alus,  916 


Atlas,  dislocation  of,  677 
Atresia  of  vagina,  357 
Atrojjhy,  ischemic,  NOl 
Avulsion  of  scalp,  61(1 
Axilla,  examining  infected,  747 

scar-formation  in,  518 
Axillary  artery,  779 


Babcock,  W.  W.,  597 

Bal)inski,  655 

Bacillus,  Oppler-Boas,  147 

typhosus,  KiS 
Baker,  W.  H.,  282 
Balanitis,  439 
Balch,  F.  G.,  892 
Baldwin,  Heniy  C,  635 
Ballance,  Charles  A.,  642,  648,  652,  653, 

654,  658,  695 
Bandage,  four-tailed,  920 

Martin,  976 
Bands,  Halsted's  metallic.  786 
Banti,  190 
Barker,  L.  F.,  212 
Barney,  J.  D.,  450 
Bartlett,  W.,  210,  348 
Bartlett's  filigree,  219 
Base,  fracture  of,  622,  633 
Basedow's  disease,  600 
Bassini,  212,  215 
Battey,  297 
Battle,  32 

Beach,  H.  H.  A.,  204 
Beard,  848 
Beatson,  848 

Beck,  Carl,  236,  459,  479,  559 
Becker,  H.,  276 
Beebe,  S.  P.,  601,  847 
Beer,  Edwin,  60 
Bell,  Charles,  670 
Belts,  abdominal,  62 
Bence- Jones,  651,  686,  834 
Benign  growths,  845 

tumors,  818 
Bennett's  fracture,  894 
Berger,  978 
Bessel-Hagen,  190 
Bethe,  Albrecht,  695 
Be  van,  Arthur  Dean,  71,  465 
Bevan's  operation,  465 
Beyea,  246 

Bickham,  176,  707,  708,  791,  965,  967 
Bier,  978 

Bier's  hyperemic  treatment,  251,  795 
Bigelow,  Henry  J.,  388,  401,  935,  937 
Bigelow's  evacuator,  367,  399,  401 
Bile-passages,  168 

acute  inflammation  of,  171 

cancer  of,  173,  179 

reasons  for  operation  on,  173 

three  laws  of  operative  treatment  of, 
174 
Bilious,  170 
Biflroth,  127,  150,  573 
Binnie,  Jolm  F.,  176,  372,  575,  605,  691, 

701 


INDKX 


995 


Birth-mark,  550 

liisliop,  212 

likulder,  absence  of,  389 

double,  389 

iliainage  of,  403 

examination  of,  362 

ex.stropliy  of,  388 

extirpation  of,  total,  407 

foreign  bodies  in,  411 

gunshot  wound  of,  410 

injuries  to,  409 

irritable,  397 

rupture  of,  diagnosis  of,  410 
extraperitoneal,  410 

sacculation  of,  408 

stone  in,  398 

suprapubic  puncture  of,  394 

tumors  of,  405 
diagnosis  of,  406 

ulcer  of,  404,  405 
Blake,  J.  B.,  221,  448 
Bland-Sutton,  J.,  555,  561,  562,  570,  617, 

686,  818,  820,  825,  840 
Blood,  transfusion  of,  388 
Bloodgood,  Joseph  C,  210,  212,  523,  527, 

768,  832 
Blood-vessels,  772 

suture  of,  792 
Boils,  752 
Boise,  768 
Boisseau,  363 
Bone  abscess,  948 

intermaxillary,  537 

syphilis  of,  949 

tuberculosis  of,  948 
Bones  and  joints,  843 

malar,  919. 

nasal,  917 

of  cranium,  650 

of  face,  917 

of  foot,  dislocation  of,  940 

of  forearm,  fracture  of,  884 
Borel,  623 

Boston  City  Hospital,  156 
Bottini,  420 

Bottomley,  John  T.,  389 
Bougies,  olivary,  457 

Trousseau's  olive-tipped,  113 
Bovee,  356 

Bowels,  anatomy  of,  43 
Brachial  artery,  780 

plexus,  714 
Bradford  (E.  H.)  frame,  679,  903 
Brain,  619,  652 

abscess  of,  653 

compression  of,  624,  632 

concussion  of,  623,  632 

contusion  of,  629 

tumor,  653 

symptoms  of,  655 
treatmnet  of,  657 

wounds  of,  630 
Brasdor  method,  791 

operation,  787 
Brashear,  Walter,  987 
Brauer,  482 


Breast,  abscess  of,  529 

actinomycosis  of,  531 

amputation  of,  Warren's  operation,  516 

and  nipples,  supernumerary,  532 
'caked,"  530 

cancer  of,  507 
colloid,  510 
en  cuirasse,  508,  51 1 
Jackson's  operation  for,  520 
meduUaiy,  507,  509 
scirrhus,  507,  508 
"withering  scirrhus,"  507 

cystadenoma  of,  525,  526 

cysts  of,  retention  of,  532 

echinococcus  of,  531 

fibrocystadenoma  of,  525 

fibroma  of,  periductal,  524 

galactocele  of,  531 

hypertrophy  of,  diffuse  mammary,  526, 
527 

involution  of,  abnormal,  527 

mastitis  of,  529 

myxoma  of,  periductal,  524,  525 

resection  of,  plastic,  527 

sarcoma  of,  periductal,  524 

syphilis  of,  531 

tuberculous  disease  of,  531 

tumors,  Warren's  classification,  523 
Bregma,  637 
Brewer,  G.  E.,  60 
Briggs'  cannula,  593 
Briggs,  C.  E.,  64,  67,  594 
Briggs,  J.  E.,  422 
Brodel,  Max,  255,  372,  373 
Brodel's  white  Hue,  372 
Brodie,  Benjamin,  721,  960 
Bronchi,  478 

foreign  bodies  in,  479 

and  limgs,  478,  487 
Broncliiectasis,  480 
Brooks,  W.  A.,  Jr.,  20,  750 
Brooks'  incision  for  palmar  abscess,  751 
Brown,  G.  V.  I.,  534 
Brown,  Tilden,  363 
Brown's  compression  apparatus,  542 
Brunn,  236 

Bryant,  Thomas,  176,  192,  358,  783 
Bubo,  447,  448 

gonorrheal,  439 
Buck,  Gurdon,  17 
Buck's  extension,  901 
Bulb,  hemostatic,  422 
Bullet,  imbedded,  924 
Bunge,  979 
Bunions,  757 
Bunts,  F.  E.,  141 
Burkhardt,  162 
Burns,  813 

of  chest,  503 

cicatrix  from,  587 

of  neck,  586 
Burrage,  W.  L.,  305 
Burrell,  Herbert  L.,  754,  778 
Bursa,  801,  808 

subdeltoid,  808 

suprapatellar,  808 


996 


JXDKX 


Bursa,  tuberculosis  of,  812 

tumors  of,  812 
Jiursitis,  808 

acute  infective,  812 

chronic,  812 

prepatellar,  809 

trauniutie,  treatment  of,  809 
Butler,  672 


Cabot,  A.  T.,  248,  910 
Cabot,  Hugh,  421 
Cabot's  ])osterit)r  wire  splint,  910 
Cahier,  Leon,  59 
Calculi,  pancreatic,  183,  184 
prostatic,  414 
renal,  370 
ureteral,  371 
urethral,  452 

urinary,  symptoms  of,  370 
Callosity,  761 
Callus,  856 
Cammidfie,  184,  185 
Cami)l)ell,  193,  372,  389,  627 
Canal  of  Nuck,  280 
Cancer,  gastric,  126,  145 
gland,  845 
of  anus,  100 

of  bile-passages,  173,  179 
of  breast,  507 
colloid,  510 
en  cuirasse,  508,  511 
Jackson's  operation  for,  520 
medullary,  507,  509 
j)r()gnosis  of,  514 
scirrhus,  507,  508 
withering,  507 
symptoms  of,  513 
treatment  of,  514 
of  cervix,  306 
of  esophagus,  125,  126 
of  fundus,  145,  306 
of  ileocecal  region,  80 
of  intestines,  77,  78 
of  jaw,  564 
of  kidney,  385 
of  larynx,  583 
of  lip,  548 

Grant's  operation  for,  551 
of  lung,  486 
of  neck,  549 
of  pancreas,  184 
of  ))enis,  450 
of  prostate,  415,  428 

excision  of,  429,  430,  431,  432 
of  rectum,  106,  108 

percentage  of  deaths  from,  108 
symptoms  of,  108 
treatment  of,  108,  109 
of  testicles,  476 
of  thyroid  gland,  610 
of  tongue,  571 

operation  for,  572 
of  uterus,  305 
diagnosis  of,  309 
symptoms  of,  308 


Cancer  of  uterus,  treatment  of,  309 

scirrhus,  107 

squamous-cell,  843 
Cannon,  W.  B.,  230 
Cannula,  Briggs',  593 
Carbon  dif)xid  snow,  557,  837 
Carbuncle,  752,  754 

excision  of,  755 

of  upper  lip,  555 
Cardiolysis,  499 
Cardiospasm,  120 

acute,  120 

chronic,  120,  121 
Cargile  membrane,  236,  707 
Caries,  945 

necrotic,  559 
Carlsbad,  170 
Carotid  artery,  external,  779 

glaml,  595 
internal,  779 
Carpus,  fracture  of,  891 
Carrel,  Alexis,  792 
Cartilages,  semilunar,  940 
Caruncle,  urethral,  352 
Cases,  study  of,  719 
Caspar,  363 
Castration,  470,  477 
Catarrh  of  appendix,  22 
Cathelin,  364 
Catheter,  ureteral,  364 
Catheterization,  390 
Cathn,  985 
Cauda  equina,  678 
tumors  of,  689 
Cavernous  tumors,  776 
Cellulitis,  pelvic,  320 
Cephalocele,  643 
Ceppi,  929 

Cerebellar  tumors,  656 
Cerebral  abscess,  652 

hemorrhage,  (i29 

localization,  634 

tumor,  653 
Cerebri,  hernia,  658,  659 

fungus,  658,  659 
Cerebrospinal  fever,  648,  680 

rhinorrhea,  645 
Cervical  abscess,  deep,  594 

adenitis,  589 

rib,  596 
Cervix  uteri,  cancer  of,  306 

erosions  of,  269 

ureters  and,  259 
Championniere,  Lucas,  194,  212 
Chancre,  444 

treatment  of,  445 
Chancroid,  445 

treatment  of,  447 
Chaput,  141 
Charcot's  disease,  972 
Cheever,  D.  W.,  124,  479,  579 
Cheiloplasty,  Sandelin's,  552 
Chelius,  736 
Chelius'  Surgery',  192 
Chest-wall,  burns  of,  503 

contusions  of,  502 


INDEX 


997 


Chest-wall,  tumors  of,  r)04 

Cheyne,  W.,  514 

VWwiw,  (VAS 

('liill)Iiiins,  815 

C'liiklrcn,  fracture  of  thigh  in,  903 

Chipault,  (J35,  691 

Choked  disk,  G2G,  641 

Cholangitis,  128,  167,  168,  169,  170,  171 

ac-ute,  172 
Cholet-ystduodcnostomy,  1 79 
Cholecystectomy,  174,  175,  177,  179 
Cholecystendysis,  175 
Cholecystenterostomy,  175,  179,  184 
Cholecystitis,  167,  168,  170,  171,  172 
Cholecystostomy,  174,  177,  184 
Choledochenterostomy,  176 
Choledocholithotomy,  175 
Choledochotomy,  175 
Cholestrin,  168 

Chondrodystrophia  foetalis,  952 
Chondroma,  828 

of  parotid  gland,  575 
Chopart's  operation,  982 
Chordee,  437 
Chylothorax,  488,  -495 
Cicatricial  contractions  of  neck,  586 
Cicatrix  from  burn,  587 
Ciechanowski,  415 
Circulation,  portal,  73 
Circumcision,  448,  449 

of  leg,  775 
Cirrhosis,  129 

gastric,  144 

of  liver,  Hanot's,  164 
Cirsoid  aneuiysm,  556,  557,  618,  776 
Civiale,  Jean,  400 
Cladothrix,  70 
Clamp  and  cauteiy,  97 
Clark,  Alonzo,  229,  230 
Clark,  J.  G.,  316 
Clavicle,  fracture  of,  863 

dislocation  of,  926 
Claw-hand,  715,  717 
Cleft-palate,  532,  540 

operation  for,  543 
Cleveland,  351 
Cline,  670 

Closed  fractures,  729,  852 
Clowes,  847 
Coagulation  time,  177 
Cobb,  Farrar,  377,  992 
Cobb's  (F.  C.)  splint,  918 
Codman,'E.  A.,  808,  809,  810,  811,  919 
Codman's  rhinoplasty,  546 
Coffey,  Robert  C,  232 
Cohnheim's  embryonal  hypothesis,  820 
"Cold  abscess,"  949,  960 
Coley,  W.  B.,  212,  848 
CoUc,  appendiceal,  22 
Colitis,  63 

mucous,  63 
Collapse,  767 
Colles'  fracture,  886 

old,  891 
Colloid  cancer  of  breast,  510 

goiter,  609 


Colon,  idiopathic  dilatation  of,  76 

Colostomy,  64,  92,  111 

Coma,  634 

C'omminiited  fracture,  850 

Common  iliac  artery,  780 

ComjOTund  fracture,  736,  850,  858,  912 

of  vault,  623 
Compression  apparatus.  Brown's,  542 

of  brain,  624 

elastic,  726 
Concussion  of  brain,  623 

of  fjpine,  674 
Condyloma,  106 
Cone,  C,  323 
Congenital  hernia,  193 

hydrocele,  473 

imbecility,  662 
Conjunctivitis,  gonorrheal,  434 
Connective-tissue  tumors,  826 
Contracture,  Volkmann's,  801,  802 
Contrecoup,  622 
Contusion  of  abdomen,  251 

of  brain,  629 

of  chest,  502 

of  joints,  955 

of  scalp,  614 

of  spine,  674 
Conus  medullaris,  tumors  of,  689 
Convulsive  tic,  712 
Coolidge,  A.,  Jr.,  479 
Coolidge's  (A.)  splint,  918 
Cooper,  Astley  P.,  505,  670,  780,  936 
Cord,  spermatic,  twisted,  477 

spinal,  anatomy    and    physiology    of, 
670 
wounds  of,  675 
Corns  (clavus),  757,  760 
Coronoid  process,  fracture  of,  886 
Corpus  luteum,  335 

cysts  of,  335 
Cotting's  operation,  759 
Cottle,  C.  H.,  484 
Cotton,  F.  J.,  851 
Courvoisier's  law,  173 
Cowper's  gland,  433 
Coxa  valga,  972 

vara,  970 
Craig,  Daniel  H.,  20,  307 
Craik,  581 

Crandon,  L.  R.  G.,  233,  415 
Cranial  bones,  tumors  of,  650 

defects,  663 
Craniocerebral  topography,  635 
Craniotomy,  osteoplastic,  663 
Cranium,  650 
Crede,  774 
Cremaster,  207 
Crile,  George  W.,  290,  497.  543,  551,  586, 

590,  601,  767,  769,  778,  846,  847 
Crile's  clamp,  554,  568 
Cross-bow  incision  (Cushing's),  667 
Crow-bar  case  (Harvard),  631 
Cullen,  323 

Cunningham,  J.  H.,  384 
Curling,  92 
Curtis,  G.  Lenox,  560 


998 


INDEX 


Cushinp,  Harvey,  G-4,  67,  22i3,  497,  GKi, 

G17,  020,  ()29,  037,  038,  040,  042,  044, 

04'),  OoO,  052,  053,  008,  077,  (i<»S,  705, 

711,  712 
Cushing's  metliod  of  closing  sculp,  007 
Cutaneous  horn,  838,  839 
Cut-tliroat,  578 
Cyliiitlroma,  830 
Cyrtometer,  Horsley's,  638 
Cystadenonia,  525 

papillaiy,  526 
Cystic  arteiy,  177 

goiter,  003,  GOG 
Cystitis,  394 

acute,  390 

gonorrheal;  440 

in  female,  397 

treatment  of,  396 

tuberculous,  395 
Cystoceie,  192,  346,  347 
Cystoma,  335,  821 
Cystoscope,  362 
Cystoscopy,  364,  305 
Cystotomy,  suprapubic,  402 

transperitoneal,  408 
Cysts,  dental,  501 

dermoid,  189,  336,  824 

echinococcus,  157,  504,  822 

follicular,  334 

hydatid,  185,  189,  822 

lymphatic,  594 

of  alveolar  process,  501 

of  breast,  retention,  532 

of  broad  ligament,  330 
dermoid,  331 

of  liver,  157 

of  mesentery,  821 

of  scalp,  dermoid,  017 

of  spleen,  188 

of  testicle,  dermoitl,  476 

ovarian,  334 
twisted,  336 

ovula  Nabothi,  269 

pancreatic,  185,  186 

retention,  820 

retroperitoneal,  241 

tliyroglossal,  548 

tubo-ovarian,  322,  325 

vaginal,  357 
Czerny,  212,  584 


Da  Costa,  J.  C,  194,  366,  482,  772,  817 

Dactylitis,  949,  950 

Dartmouth,  338 

Davis,  Byron  B.,  187 

Davis,  G.  G.,  210,  212 

Davis,  Lincoln,  405 

Dawbam,  Robert  H.  M.,  757 

Deaver,  J.  B.,  17,  31,  36,  296 

Decapsulation  of  kidney,  380 

Deciduoma  mahgnum  (choriodeciduoma), 

318 
Decompressive  operations,  667 
DeGarmo,  W.  B.,  193,  201,  202,  205 
Degeneration,  myxomatous,  837 


Degeneration  of  scars  and  ulcers,  malig- 
nant, 817 
de  (juise,  operation  of,  547 
Delagenifere,  104 
Delayctl  union,  852 
Delonne,  operation  of,  493 
Denans,  42 

Dennis,  F.  S.,  212,  496,  624 
Dental  cysts,  561,  562 
Dermoid  cysts,  824 

of  broad  ligament,  331 
of  ovaries,  470 
of  scalp,  017 
of  testicle,  476 
Desault  splint,  913 
Desmoids,  252,  827 
DeVilbiss  forceps,  665 
Diaphragmatic  liemia,  192 
Diarrhea,  tubular,  0;5 
Diathesis,  gouty,  309 
Dieffenbach,  018 
Dietl's  crisis,  247 
Dieulafoy,  130 
Diffuse  goiter,  602 

lipoma,  827 
Digestive  organs,  128 
Dilatation  of  the  colon,  idiopathic,  76 

gastric,  61 
Dilators,  Goodell-Ellinger,  207 

Hanks',  207 
Disarticulation,  wrist,  991 
Disinfecting  skin,  725 
Dislocation  of  atlas,  677 

of  clavicle,  926 

of  elljow,  922 

old  unreduced,  934 

of  forearm,  backward,  of  both  bones, 
881 

of  foot,  bones  of,  940 

of  hip,  935 

of  jaw,  lower,  940 

of  knee,  739 

of  patella,  ^rS9      t  -^  '  • 

of  radius,  head  of,  933' 

of  shoulder,  927 
old  unreduced,  931 

of  thumb,  first  jjlialanx  of,  934 

of  vertebra^,  676 

of  wrist,  !)34 
Diverticulitis,  58 

treatment  of,  GO 
Diverticulum,  114 

Meckel's,  50,  57,  58,  59 

of  esophagus,  122,  123 

of  sigmoid,  59 
Dolhnger's  method,  591,  592 
Donald,  207 
Douglas,  F.  B.,  242 
Dowd,  Charles  X.,  801 
Druitt,  192 
Drummond,  163 
Duct,  bile-,  168 

ejaculatory,  412 

Mailer's,  319 

of  Santorini,  109 

of  Wirsung,  168,  169,  182 


INDEX 


999 


Duct,  pancreatic,  1G9 
prostatic,  412 
thoracic,  wouiuls  ot_,  593 
vitello-iutostinal,  57 

dS^ ";  C^O,,  27.  277,  300  30,, 
302,  30(',,  309,  312,  313,  3Io,  319,  S2., 
329,  351,  356  . 

Dudley's  operation  tor  anteflexion,  2&b 

Dunham,  Theodore,  119 

Duodenal  ulcer,  30,  129,  130,  lol,  133, 
142.  173 

Duodenum,  113,  12S,  168 

Dupuytren's  splint,  91o 

du  Rocher,  363 

Dysphagia,  116,  123,  12o 


EcHiNOCOCcrs  disease,  157,  504,  S22 

of  Kmg,  485  _^  I 

of  mammaiy  gland.  531  1 

of  pleura,  495  ^ 
Ectopic  gestation,  340 
Ectropion,  545 

Edebohls.  George  :\I.,  249,  2o0,  38b 
Edward,  J.  R..  4S4 
Effusion,  pericardial,  49/ 
EhrUch,  847 

Eichberg,  Joseph  E.,  237 
Einhorn.  113  __ 

Eisendrath,  Daniel X.,  199,  o/2,  849,  896, 

942 
Elastic  compression,  /26 
Elbow,  dislocation  of,^932 
old  unreduced,  934 
excision  of,  964 

fracture  of,  877  ,     ^    ,    oqq 

Elbow-joint,  fracture  of,  neglected,  8S3 
Elephantiasis,  797 
EUot.  EUsworth,  Jr.,  166,  16/.  499 
Embohsm  of  mesenteric  vessels, _  / 1 
Embn-onal  hji^othesis,  Cohnheim  s,  820 
Emmet.  T.  A.,  273,  350,  353 
Empyema.  490 
of  antrum.  560 
chronic,  treatment  of,  492 
EncephaUtis.  652 
Encephalocele.  643 
Encephalocystocele.  643 
Endocervicitis.  269 
Endometritis,  271 
acute.  268 
cervical.  269 
chronic,  268 
EndotheUoma.  654,  834 

of  uterus,  317 
Enema,  lime-water.  93 
Enlargement,  prostatic.  390 
Enteritis,  membranous,  63 
Enterocele,  192 
Enterolith,  5G 
Enteroptosis,  60,  243 
Enterostomy.  52,  231 
Enucleator.'Mavo's  vein,  775 
Ependyma,  643,  649 
Epidemic  meningitis,  680 


Epididymitis,  437 

syphilitic,  468 
Epilepsy,  660 
focal,  661 

Jacksouian,  655,  661 
treatment  of,  661 
Epiphysis,  separation  of  upper,  8/1 
Epiplocele,  192 
Epispadias,  459 
Epithelial  tumor.;,  838 
Epulis,  562,  563 
Erasion  of  joints,  964 
Erichsen,  John  E.,  674,  990 
Erosions,  130 
of  cervix,  269 
exulceratio  simplex,  130 
gastric,  130 
Erj'sipelas,  facial,  555 

toxins  of,  848 
Erji:hema  pernio,  815 
Escher,  162 
Esmarch,  90,  976 
Esophageal  stricture^  114,  llo 
diagnosis  of,  118 
treatment  of,  118 
tube,  Svmond's,  116 
Esophagitis,  120  ..    ,o„    i--,- 

Esophaioscope,  114,  121,  124,  12o,  12. 
Esophagoscopy,  115 
Esophagotomy,  114,  124,  12o 
Esophagus,  113 

actinomycosis  of,  127 
cancer  of,  125,  126 
diverticulum  of,  122,  123 
foreign  bodies  in,  12_3 
inflammation  of,  127 
injuries  of,  126 
kinking  of,  120 
tumors  of,  125 
ulcers  of,  127 
Estlander's  operation,  492,  493 
Eustache,  534 
Evans,  608 

Ewine,  AV.  G..  240.  847 
Excision  of  ankle-jomt.  969  ^ 

of   cancer  of  prostate,   429,  4o0,  4ol, 

432 
of  carbimcle,  755 
of  elbow,  964 
of  hip-joint.  966 
of  jaw,  568 
of  joints,  964 
of  knee-joint.  967 
of  parotid  gland,  575 
of  wrist-joint,  965 
Exophthalmic  goiter,  597,  600 
Exostosis,  828 

Exploration,  sub-occipital,  bb7 
Extension,  Buck's,  901 
Extradural  hemorrhage,  627 


Face,  bones  of,  917 
injuries  of.  555   . 
plastic  operation  on,  544 
powder,  545 


lUOO 


iM)i:x 


Face,  tumors  of,  556 
I'acial  artery,  779 
erysipelas,  55o 
paralysis,  712 
spasm,  712 
Fallopian  tubes,  ojjeration  on,  conserva- 
tive, '.i2\) 
tumors  of,  329 
Farina,  496 
Fat-necrosis,  183 
Fecal  fistula,  52,  71,  82,  83,  84 
treatment  of,  84 
tumors,  57 
Feeding  by  gastrostomy,  153 
Feiss,  Henrj'-  ().,  971 
P'cll-O'Dwyer  apparatus,  482 
Felon,  745 
Femoral  arteiy,  780 
hernia,  195 
ring,  192 
Femur,  fracture  of,  895 
neck  of,  896 
shaft  of,  900 
supracondyloid,  903 
Fenger,  375 
Fenwick,  363 

Ferguson,  A.  H.,  212,  386,  426 
Fever,  cerebrospinal,  648,  680 
"spotted,"  648 
typhoid,  65 
Fibroadenoma,  840 
Fibrocystadenoma,  525 
Fibroid,  292 
Fibroma,  827 

of  breast,  periductal,  524 
of  jaw,  561 
Fibromyoma,  292,  837 
Fibula,  Pott's  fracture  of,  913 
Filaria  sanguinis  communis,  796 
Filariasis,  796 
Fillebrown,  542,  543 
Finger,  415 

Finney,  J.  M.  T.,  132,  134,  136,  140,  141 
First  intention,  725 
Fischer,  G.,  496,  597,  793 
Fissui-e  of  anus,  94 
of  Rolando,  638 
of  Sylvius,  638 
Fistula,  52,  71,  82,  83,  84,  96 
operation  for,  99 
complete,  97 
external,  blind,  97 
fecal,  52,  71,  S2,  S3,  84 

treatment  of,  84 
forms  of,  98 
in  ano,  97 
internal,  82 
blind,  97 
rectovaginal,  353,  355 
salivary,  547 
umbihcal,  254 
urethral,  458 
urethrovaginal,  353,  354 
urinary,  354 
vesico-uterine,  353 
vesico-uterovaginal,  353,  354 


Fistula,  vesico-vaginal,  353,  354 

Fitz,  R.  11.,  17,  30,  7(),  154 

Flexner,  S.,  648,  680 

Flint,  Carleton  1>.,  906,  967,  968,  969,  970 

Focal  epilepsy,  661 

Follicular  cysts,  334 

odontoma,  562 
Foot,  amjjutation  of,  982 
bones  of,  dislocation  of,  940 
phalanges  of,  917 
Foramen  of  AVinslow,  76 
P'orearm,  bones  of,  dislocation  backward 
of  jjoth,  881 
fracture  of,  884 
Foreign  body   in  bladder,  4 1 1 
in  bronchi,  479 
in  esophagus,  123 
in  intestines,  56 
in  larjmx,  579 
in  rectum,  92 
in  trachea,  579 
in  urethra,  451 
Fossa,  intersigmoid,  76 
navicularis,  433,  435 
retrocecal,  76 
retroduodenal,  76 
Fothergill,  267 
Four-tailed  bandage,  920 
Fowler,   George   Ryerson,   40,   212,   232. 

282,  365,  375,  429,  440,  494 
Fowler,  Russell  S.,  232 
Fowler's  operation,  493,  494 

position,  55,  81,  231,  233,  783 
Fracture,  849,  853 
Bennett's,  894 
closed,  729,  852 
Colics',  886 

compound,  736,  850,  858,  912 
greenstick,  854 
gunshot,  924 
immobilization  of,  730 
open,  736,  852 

treatment  of,  851 
pathologic,  854,  924 
periosteal,  854 
punctured,  622 
simple,  729,  850,  854,  855 
spiral,  854 
of  base,  622,  633 
of  carpus,  891 
of  clavicle,  863 

old,  891 
of  coronoid  process,  886 
of  elbow,  877 

neglected,  883 
of  femur,  895 
neck  of,  896,  899 
shaft  of,  900 
su]>racondyloid,  903 
of  fibula,  Pott's,  913 
of  forearm,  bones  of,  884 
of  humerus,  868 

anatomic  neck  of,  871 
lower  enil  of,  879 
surgical  neck  of,  872 
of  hyoid,  579 


INDEX 


1001 


Fracture  of  jaw,  lower,  922 
UpjHT,  !)2() 

of  leg,  907 

of  patella,  904 

of  pelvis,  8()2 

of  plialanges,  895 

of  radius,  liead  and  neck  of,  886 
neck  of,  881 

of  ribs,  859 

of  scaphoid,  892 

of  sca])ula,  867 

of  skull,  620 

of  sternum,  861 

of  thigh  in  children,  903 

of  thyroid,  579 

of  vault,  compound,  623 
simple,  623 

of  vertebrae,  676 
Fragilitas  ossium,  952 
Frame,  Bradford,  903 
Frank,  Jacob,  163,  212 
Frankel,  495 

Frazier,  Charles  H.,  613,  709 
Frederick,  Emperor,  584 
Freudenberg,  420 
Freyer,  423 
Friedrich,  484 
Fritsch,  635 
Frost-bite,  815 
Fuller,  Eugene,  444 
Fundus  uteri,  cancer  of,  306 
Fungus  cerebri,  658,  659 
Funke,  John,  595 


Galactocele,  531 

Galen,  669,  772 

Gall-bladder,  enlarged,  172 

Gall-stones,  169 

Gamgee,  Sampson,  724,  742,  853 

dressing,  754 
Ganglion,  Gasserian,  699,  702 

Cushing's  operation  upon,  703 

tuberculous,  806 
Gangrene,  22,  73 

of  lung,  485 
Gangrenous  appendicitis,  22 
Garceau,  Edgar,  3{57 
Garrigue,  351 
Gastrectasia,  128 
Gastrectomy,  148 
Gastric  adhesions,  143 

cancer,  diagnosis  of,  147 
symptoms  of,  147 

cirrhosis,  144 

dilatation,  61 

erosions,  130 

hemorrhage,  141 

ptosis,  61 

surgery,  127 

tetany,  129,  144 

ulcer,  128,  133 
Gastroduodenostomy,  Finney's,  136 
Gastroenterostomy,    127,   134,   140,   142, 
179 

anterior,  134 


Gastroenterostomy,  posterior,  135 
Gastrogastrostomy,  143 
Gastroplasty,  132 
Gastroptosis,  129,  144,  243 
Gastrostomy,  64,  121,  126,  151,  152 

feeding  by,  153 

preliminaiy,  119 

Witzel's,  64 
Gatch,  232 

Gay,  George  W.,  100,  473,  848 
Gaylord,  847 
General  condition,  720 
Genital  herpes,  448 

lesions  of  syphilis,  444 
Genito-urinary  organs,  358 
Gerhardt,  73 
Gerlach,  valve  of,  18,  20 
Gersuny,  389 
Gersuny's  method,  814 
Giant-cell  sarcoma,  832 
Gibbon,  John  H.,  500 
Gibson,  C.  L.,  48,  75,  419 
Gilliam,  282 

Gimbemat's  ligament,  213 
Girard,  212 
Glabella,  637,  665 
Gland  cancer  845 

carotid,  595 

Cowper's,"433 

in  neck,  589 

lymph,  796 

of  Littre,  433 

parotid,  excision  of,  575 

salivary,  574 

suprarenal,  382 
tumors  of,  386 

swollen,  590 

thyroid,  597 
cancer  of,  610 
Glandules,  parathyroid,  597,  608 
Gleet,  441 

treatment  of,  442 
Gl^nard,  60,  243,  244,  245 
GMnard's  disease,  60 
Glioma,  654,  838 
Gliosarcoma,  689 
Glossitis,  chronic,  570 
Gluck, 162,  584 
Gluteal  hernia,  192 
Goiter,  597,  602 

aberrant,  611 

causation  of,  604 

colloid,  609 

cystic,  603,  606 

diagnosis  of,  604 

diffuse,  602 

exophthalmic,  597,  600 

malignant,  treatment  of,  611 

treatment  of,  604 
Goldspoon,  351 

Goldthwait,  J.  E.,  244,  812,  957 
Gonococci  of  Neisser,  435 
Gonorrhea,  269,  434 

acute,  treatment  of,  436 

chronic,  441 

of  rectum,  93 


1002 


INDEX 


Gonorrheal  bubo,  439 

conjunctivitis,  434 

cystitis,  440 
Goodcll-l'lUinger  tUlators,  267 
Gottschalk,  297 
GouUl,  A.  II.,  135,  136 
Gouley,  391 
Grafting,  nerve,  711 
Grafts,  Wolff,  815 
Graluun,  Douglas,  763 
Grunt,  W.  \V.,  5.")2 

Gnint's  operation  for  cancer  of  lip,  551 
Granulating  wounds,  740 
Granulations,  exuberant,  741 

Pacchionian,  643 
Granuloma,  infectious,  654 
Graves,  W.  P.,  279 
Graves'  disease,  600 

psychic  aspect  of,  601 
treatment  of,  601 
Grawitz,  P.,  382,  383 
Greenough,  R.  B.,  163,  231 
Green-stick  fracture,  854 
Gritti,  978 
Growths,  benign,  845 

malignant,  845 
Grtmbaum,  638 
Guaiac  test,  132 
Gunkel,  99 
Gunshot  fractures,  924 

wounds  of  bladder,  410 
"Gunstock  elbow,"  852 
Guthrie,  Charles  C,  792 


Hall,  Basil,  191,  212 

Halstead,  A.  E.,  57 

Halsted,  William  S.,  212,  515,  608,  610, 

780 
Halsted's  metallic  bands,  786 

operation,  210,  211 
Hamilton,  A.  J.  A.,  427 
Hand  amputations,  991 
Handley,  W.  S.,  512 

theory  of,  842 
Hanks'  dilators,  267 
Hare,  772 
Harelip,  532,  534 

double,  537 

operation,  a  dressing  after,  539 
position  for,  536 

treatment  of,  535 
Harrington,  F.  B.,  408 
Harris,  M.  L.,  164,  364,  429 
Harte,  R.  H.,  64,  67 
Hartley,  705 

Hartwell,  John  B.,  107,  108 
Harvard,  58,  129,  130 
Hawkins,  30,  236 
Head,  613 

lesions,  symptoms  and  diagnosis  of  or- 
ganic, 634 
Headache,  641 
Heart,  496 

wounds  of,  499 
Heath,  200,  339 


Ilcidenliain,  357 
Ileinricius,  189 
Heister,  670 
Hclferich,  888,  934,  941 
Ilelmholz,  H.  F.,  617 
Hematocele,  468 

pelvic,  341,  344 
Hematoma  of  ovary,  336 

of  scalp  615 
Hematomyelia,  675,  676 
Hematosalpinx,  320,  344 
Hemorrhage,  976 
cerebral,  629 
extradural,  627 
gastric,  141 
intestinal,  65 
intracranial,  627 

of  newborn,  629 
subdural,  628 
Hemorrhoids,  89,  99 
external,  100,  102 
internal,  100 
mixed,  100 
operation  for,  101 
Hemostatic  bulb,  422 
Hemothorax,  488,  495 
Hepatic  arteiy,  aneurysm  of,  167 
Hepatoptosis,  165,  166,  243 
Hernia,  abdominal,  192 
cerebri,  658,  659 
congenital,  193,  215 
diaphragmatic,  192,  220 
direct,  201 
duodenal,  221 
epigastric,  192 
femoral,  195,  213 

treatment  of,  214 
gluteal,  192 
incarcerated,  196 
indirect,  201 
inguinal,  192,  199 
direct,  210 
in  women,  213 
oblique,  206 
in  women,  195 
internal,  76 
irreducible,  196,  205. 
lumbar,  192 
multiple,  194 
obturator,  221 
pelvic,  289 
perineal,  289 
radical  cure  of,  198 
reducible,  195 
retroperitoneal,  193,  221 
sciatic,  192 
scrotal,  192,  204 
strangulated,  196,  197 

treatment  of,  198 
umbilical,  215 
of  adults,  216 

treatment  of,  216 
of  infants,  216 
ventral,  192,  219 
Herniotomy,  199 
Herpes,  genital,  448 


INDEX 


1003 


Hosselbach's  triangle,  201 
Hey,  418 

Hey's  operation,  982 
Hill,  L.  L.,  363,  499 
Hip,  dislocation  of,  935 

fracture  of,  ununited,  899 
Hip-joint,  am])utation,  987 

excision  of,  966 
Hippocrates,  398,  488,  772 
Hij){)ocratic  facies,  50,  227 
Hirsch,  978 

Hirst,  Barton  Cooke,  331  , 

His,  613 
Hitzig,  635 
Hochenegg,  389 
Hodgkins'  disease,  799,  800 
Hoffa,  939 
Hoffmann,  444 
Holm,  162,  242 
Holmes,  784 
Homans,  John,  17 
Hooper,  F.  W.,  581 
Horns,  448 

cutaneous,  838,  839 
Horse  serum,  814 
Horsley,  Victor,  613,  658 
Horsley's  cyrtometer,  638 
Hotchifiss,  Lucius  W.,  39 
Hough,  34 

"Housemaid's  knee,"  809 
Howell,  767 

Humerus,  fracture  of,  868 
lower  end  of,  879 
neck  of,  anatomic,  871 
surgical,  872 
Hunter,  John,  415,  434,  730,  772 

operation  of,  786 
Hupp,  107 

Hutchinson,  Woods,  20 
Hydatid  cysts,  822 
Hydatidiform  mole,  318 
Hyde,  392 
Hydrocele,  470,  823 

congenital,  473 

of  neck,  594 

of  round  ligaments,  330 

of  tunica  vaginalis,  471 

treatment  of,  472' 
Hydrocephalus,  644 
Hydromyelia,  681 
Hydronephrosis,  371,  374,  375 

false,  374 

intermittent,  374 
Hydrops,  961 

of  appendix,  22 
Hydrosalpinx,  320,  322 
Hydroscope,  471 
Hydrotherapy,  766 
Hydrothorax,  488,  494 
Hydroureter,  308 
Hyoid  bone,  fracture  of,  579 
Hyperemia,  passive,  963 
Hyperemic  treatment.  Bier's,  795 
Hypernephroma,  382,  383,  384 
Hyperthyroidism,  600 
Hypertrophy,  diffuse  mammary,  526,  527 


Hypertrophy  of  prostate,  415 

of  rectal  valves,  90 
Hypodermoclysis,  770 
Hypospadias,  459 

balanitic,  treatment  of,  460 

Stimson's  operation  for,  460 
Hypothesis,  Cohnhein's  embryonal,  820 
Hysterectomy,  292 

abdominal,  for  cancer,  315 

pan-,  297,  303 
for  cancer,  317 

supravaginal,  297,  301 

vaginal,  310 
Hysteric  joints,  872 


Ichthyosis,  571 
Icterus,  170,  172 
Idiopathic  dilatation  of  colon,  76 

peritonitis,  225 
Iliac  artery,  common,  780 

external,  780 
Ileocecal  cancer,  80 

tuberculosis,  69 
Ileum,  21 

valves  of,  21 
Ileus,  dynamic,  48 

gastromesenteric,  52 

mechanical,  48 
Imbecihty,  662 

congenital,  662 
Immobilization,  726 

of  fractures,  730 
Imperforate  anus,  90 

rectum,  90 
Incised  wounds,  724 
Incontinence  of  urine,  397 
Indigo  carmine,  363 
Infarct,  acute,  unilateral,  septic,  377 
Infection,  acute  hematogenous,  377,  378 
Infectious  granuloma,  654 
Infective  bursitis,  acute,  812 
Inflammation  about  umbilicus,  254 

of  bile-passages,  acute,  171 

of  esophagus,  127 

of  prostate,  412 

of  rectum,  92 
gonorrheal,  93 

of  testicle,  468 

of  thyroid  gland,  611 

of  tongue,  570 

of  uterus,  261 
Inflammatory  stricture,  455 
Infusion,  intravenous  saline,  771 
Ingrowing  nail,  757 

toe-nail,  758 
Inguinal  canal,  192 

hernia,  192 
Inhalation  pneumonia,  584 
Inion,  637,  665 
Innominate  artery,  777 

aneurysm  of,  785 
Insanity,  662 
Intercostal  nerA^es,  716 

neuralgia,  504 
Intermaxillary  bone,  537 


1004 


IXDKX 


Internal  carotid  arton'.  770 
fistula,  S2,  97 
licniorrlioids,  100,  101 
hernia,  7(5 
Intersio;nK)id  fossa,  76 
Intestinal  cancer,  77,  78 
diajjnosis  of,  79 
incurable,  79 
symptoms  of,  78 
treatment  of,  79 
hemorrhage,  do 
lesions,  symptoms  of,  46 
localization,  43,  44 
obstruction,  47,  182 
acute,  48 

diagnosis  of,  50 
pathology  of,  49 
treatment  of,  50 
chronic,  53,  68 
symptoms  of,  53 
treatment  of,  54 
perforation,  55,  56 

traumatic,  diagnosis  of,  55 
ptosis,  61 

treatment  of,  62 
stenosis,  69 
strangulation,  50,  51 
Intestines,  actinomycosis  of,  69 
foreign  bodies  in,  56 
injuries  to,  54 
sarcoma  of,  77 
tuberculosis  of,  67 
tumors  of,  76 
benign,  77 
Intracranial  hemorrhage,  627 
of  newborn,  629 
operations,  technic  of,  663 
tumors,  654 
Intramedullary  tumors,  689 
Intraspinal  tumors,  laminectomy  for,  694 
Intravenous  saline  infusion,  771 
Intubation  of  larynx,  579,  581 

O'Dwyer's,  580 
Intussusception,  58,  73,  74 
Invagination,  73,  74,  78 
Involution,  abnormal,  527 
Ischemic  atrophy,  801 
Ischiorectal  abscess,  95,  9G 
Israel,  372 


Jackson,  Henry,  156 

Jackson,  James  M.,  71 

Jacksonian  epilepsy,  655,  661 

Jackson's  (Jabez  N.)  operation  for  can- 
cer of  breast,  520 

Jacobson,  176 

Jaundice,  177 

Jaw,  558 

ankylosis  of,  560,  561 
cancer  of,  564 
fibroma  of,  561 
lower,  dislocation  of,  940 
excision  of,  568 
fracture  of,  922 
reconstruction  of,  559 


Jaw,  lower,  resection  of,  564 

sarcoma  of,  563 

tumors  of,  5()1 

upj)cr,  fracture  of,  920 
resection  of,  565 
Jejunojejunostomy,  1 34 
Jejunostomy,  121,  152 
Je'pson,  189 
Jewett,  262 
Joerss,  514 
Joint,  ankle-,  excision  of,  969 

hip-,  excision  of,  966 

knee-,  excision  of,  967 

wrist-,  excision  of,  965 
"Joint-mouse,"  958 
Joints,  943,  955 

contusions  of,  955 

excision  of,  964 

hysteric,  972 

tuberculosis  of,  960 

wounds  of,  734 
Jones,  Daniel  Fiske,  409 


Kader,  152 

Kahler's  disease,  651 

Kammerer,  Frecleriek,  215 

Kausch,  78 

Keen,  W.  W.,  67,  163,  584,  595,  630,  644 

Keetley,  368 

Keith,  George  E.,  848 

Keith,  Skene,  848 

Kelly,  Howard  A.,  40,  210,  211,  255,  259, 

260,  273,  276,  282,  285,  294,  306,  307, 

308,  316,  317,  322,  328,  329,  335,  355, 

359,  362,  371,  719 
Keloid,  816,  817 
Keratosis,  570 
Kidney,  358 

carcinoma  of,  385 

decapsulation  of,  386 

floating,  247 

treatment  of,  248 

horseshoe,  360 

infection  of  one,  acute  hematogenous, 
377 

injuries  of,  366 

palpating,  361 

ruptured,  366,  367 

sarcoma  of,  384 

stone  in,  369 

surgical,  376,  377,  378 

tuberculosis  of,  380 

tumors  of,  381 

wt)untls  of,  368 
Killian,  480 
Kingscote,  212 
Klebs,  125 

Knee,  dislocated,  939 
Knipe,  Norman,  331 
Knott,  Van  Buren,  160,  161,  232 
Koch,  591 

Kocher,  Albert,  598,  599,  601,  609 
Kocher,  Theodor,  86,  109,  110,  111,  150, 
163,   176,  212,  215,    471,   572,    605, 
624,  630,  700,  980 


INDEX 


1005 


Kocher  mptlind,  020 

for  artificial  anus,  S6 
Konis;.   171,  U(il2 
Korto,  82 
Kousnetzoff,  1G3 
Kovnvor,  101 

Kraske,  100,  110,  111,  212 
Klaus,  120 
Kreilel,  071 
KrishalHT,  ■')83 
Kiunlein,  R.  N.,  630,  638 
Kurpjuweit,  404 
Ku8tor,  212,  368,  429,  078 
Kiistner,  355 


Lacerated  wounds,  732 
Laceration,  perineal,  345 
Lacunse  laterales,  643 
Laminectomy,  601,  692,  694 
Lancereaux,  E.,  786 
Landau,  243 
Langerhans,  471 
Lannelongue,  159 
Larrabee,  R.  C,  247 
Larrey,  Baron,  496,  631 
Lar\-ngectomy,  584 
Larynx,  cancer  of,  583 

extirpation  of,  partial,  585 
total,  584 

foreign  bodies  in,  579 

intubation  of,  579,  580,  581 

tumors  of,  583 
Lateral  anastomosis,  68 

perineal  route,  400 
Lauenstein's  operation,  356,  991 
LeConte,  R.  G.,  233,  992 
Le  Dran,  733 
Leg,  amputation  of,  983 

circumcision  of,  775 

fracture  of,  907 

ulcer  of,  742 

varicose  veins  of,  774 
Lejars,  581 

Lembert,  42,  84,  123,  142 
Lemonier,  534 
Lenhartz,  495 
Leptomeningitis,  647 

suppurative,  648 
treatment  of,  649 
Leukemia,  myelogenous,  190 

splenic,  191 
Leukoplakia,  571,  845 
Le"\verenz,  187 
Lexer,  242 
Leyden,  224 
Lice,  504 

Ligament,  broad,  cysts  of,  330 
dermoid,  331 
tumors  of,  330 
varicocele  of,  331 

of  Treitz,  135 
.  round,  hydrocele  of,  330 

uterosacral,  270 
Ligamentum  patellse,  808 
Ligation  of  arteries.  776 


Lilicntlial,  II.,  41,  177 
Lime-water  enema,  93 
Lingual  artciy,  779 
Liniiart,  545 
Lip,  cancer  of,  548 

upper,  carbuncle  of,  555 
Lipoma,  826 

arborescens,  826 

diffuse,  827 
Lisfranc's  operation,  982 
Lister,  17,  42 
Litholapaxy,  400,  402 
Litliotomy,  perineal,  404 
Lithotrite,  402 
Lithotritv,  400 
Little,  035 
Liver,  155 

abscess  of,  156 

approach  to,  transthoracic,  159 

cirrhosis  of,  163 
Hanot's,  164 

cysts  of,  157 

floating,  250 

ptosis  of,  62 

resection  of,  162 

syphilitic,  160 

tumors  of,  treatment  of,  161 
Lochet,  495 
Locke,  Edw-in  A.,  959 
Lock-jaw,  560 
Lodge,  Henry  Cabot,  581 
Loeb,  847 

Lothrop,  Howard  A.,  105,  891,  920 
Lovett,  Robert,  W.,  957 
Lower  jaw,  fracture  of,  922 
Lumbar  hernia,  192 

puncture,  648 
Lund,  F.  B.,  385,  944 
Lvmg,  478 

abscess  of,  484 

cancer  of,  486 

echinococcus  of,  485 

gangrene  of,  485 

injuries  of,  486 

sarcoma  of,  486 
Luys,  364 
Lymph  nodes,  792,  793 

disease  of,  malignant,  800 

of  neck,  589 

retroperitoneal,  tuberculosis  of,  239 

tuberculous,  799 

varices,  796 

vessels,  793 
Lymphadenitis,  798 

chronic,  707 
Lymphadenocele,  796 
Lymphangiectasis,  796 
Lymphangioma,  796,  837 
Lymphangitis,  704 

chronic,  706 
Lymphatic   connections    of  uterus,   257, 
260 

cysts,  594 

system,  792 

physiology  of.  703 
Lymphatics  of  stomach,  146 


1006 


INDKX 


Lynipliocystnma,  799 
Lynipliosarcoiiui,  830 

Mackenroth,  355 

Macroglossia.  570 

iMajiendic,  670 

Majrnai,  212 

Malar  bone,  919 

Malaria,  189 

Malformation  of  umhilicvis  ami  urao 

253 
.Malgaifjne,  193,  536 
Malignant    degeneration    of    scars 
ulcers,  817 

disease  of  lympli  nodes,  800 

growths,  845 

tumors,  818 
]\Ialunion,  852 
Marchand,  595 
Marjolin's  ulcer,  817 
Marshall,  340 
]Marsupialization,  608 
Martin  bandage,  976 
Martin,  Claude,  814 
Martin,  Edward,  297,  329,  351,  355, 

446 
Massachusetts  General  Hospital,  64, 

93,  217,  303,  334 
Massage,  62,  732,  762 

of  prostate,  413,  444,  853 
Mastitis,  529 

]\Iatas,  Rudolph,  482,  560,  561,  772, 
788,  790,  792,  923,  978 

splint,  922 
Maunsell,  112 
Maydl,  389 
Mayo,  C.  H.,  214,  282,  586,  601 

vein  enucleator,  775 
Mayo,  W.  J.,  60,  80,  82,   112,   135, 

148,  149,  150,  151,  162,  184,  217, 

222 
McArthur,  L.  L.,  436 
McBumey,  Charles,  17,  27,  212 

incision,  low,  32,  40 

method,  32 
McCosh,  A.  J.,  25,  386 
McDowell,  Ephraim,  338 
McEwen,  20,  21,  212 
McGraw,  SO 
McGuire,  Hunter,  780 
]\Iechanical  therapeutics,  795 
Meconium,  91 
Meier,  267 
Melanoma,  836 
Melanosarcoma,  836 
Melena,  132 

Membranous  enteritis,  63 
Meningeal  tumors,  650,  686 
Meninges,  619,  642 
Meningitis,  647 

epidemic,  680 

serosa,  648,  681 

spinal,  680 

suppurative,  680 
urotropin  in,  649 
Meningocele,  643,  681 


ami 


438, 
70, 

780, 


145, 
218. 


Meningomyelocele,  681 
Mesenteric  embolism,  71 

thrombosis,  71 
Mesentery,  87 

cyst  of,  821 

injuries  and  diseases  of,  87 
Metatarsal  bones,  917 
Metritis,  acute,  263 

chronic,  267 

symj)toms  of,  2()S 
treatment  of,  2()S 
Meyer,  Willy,  483,  794,  795,  854 
Milk-leg,  773 
Miner's  elbow,  809 
Minor  surgery,  719 
Mirault,  53(5 
Mixter,  S.  J.,  119,  120 
Moles,  839 

Molluscum  fibrosum,  617 
]Monks,  George  H.,  43 
Montgomery,  392 
IVIoore,  E.  M.,  889 
Morf,  P.  F.,  240 
Morgagni,  415 
Moriarty,  921 

Morris,  Robert  T.,  27,  170,  329 
Morrison,  163 
Morton's  fluid,  684 
Mosher,  H.  P.,  116 
Mott,  Valentine,  617,  777 
Moynihan,  B.  G.  A.,  135,  140,  167,  176, 

187,  189,  221,  222,  233 
Mucous  colitis,  63 

polypi,  106 
Mailer's  ducts,  319 
Mulligan,  E.  W.,  304 
Mulon,  596 
Mummery,  768,  771 
Munro,  J.  C,  135 
Murphy  button,  42,  69,  81,  199 
Murphy,  F.  T.,  230,  482,  977 
Murphy,  John  B.,  26,  40,  56,   112,  232, 

234,  238,  515,  519,  671,  678,  080,  681, 

686,  688,  707,  792,  884 
Musculospiral  paralysis,  716 
Myelocystocele,  682 
Myelogenous  leukemia,  190,  191 
]\Iyeloid,  832 
Myeloma,  651,  685 
Myofibroma,  837 
Myoma,  292,  837 

complicating  j^regnancy,  304,  305 

intramural,  293 

submucous,  293,  294 

subserous,  293,  298 

uterine,  symptoms  of,  293 
treatment  of,  296 
Myomectomy,  299 
Myositis,  802 
Myxoma,  837 

of  breast,  periductal,  524,  525 
Myxomatous  degeneration,  837 

Nail,  ingrowing,  757 
Nasal  bones,  917 
defects,  544 


INDEX 


loo-; 


Niisoj)li;irynx,  57(i 
Neck,  burns  ol',  58G 
carcinoma  of,  549 
contractions  of,  cicatricial,  586 
dissection  of,  552 
hydrocele  of,  594 
lyinpli-nodes  of,  589 
wiy,  58G 
Necrosis,  945 
fat,  183 

phosphorous,  569 
Necrotic  caries,  559 
Neisser,  gonococci  of,  435 
Nelaton,  536,  960 

forceps,  339 
Nelaton 's  line,  896 
Neoplasm,  818 
Nephrectomy,  378 
Nephritis,  chronic,  386 
NephroHthiasis,  369 
Nephroptosis,  243,  246,  247 
Nephrotomy,  373,  378 
Nerve  cocainization,  976 
Nerves,  anastomosis  of,  711 
in  stump,  710 
grafting  of,  711 
injuries  of,  710 
intercostal,  716 
operations  upon,  707 
peripheral,  694 
peroneal,  716 
phrenic,  713 
pneumogastric,  713 
regeneration  of,  707 
suture  of,  707,  708 
wounds  of,  710 
Neudorfer,  979 
Neuralgia,  intercostal,  504 
major,  698 
minor,  698 
reHex,  698 
Neurasthenia,  61 
Neurectomy,  tri-facial,  700 
Neurilemma,  671 
Neuritis,  695   - 

optic,  641 
Neurofibroma  of  scalp,  617 
Neuroma,  709,  838 
amputation,  709 
Neuromimesis,  872 
Neuroplasty,  708 
Neuroses,  674 
Nevus,  776 

cavernous,  556 
simple,  556 

treatment  of,  by  boiling  water,  J. 
■  Wyeth's,  557 
NichoUs,  Albert  G.,  820 
Nichols,  Edward  H.,  944,  945,  953 
Nicoll,  215 
Nipple,  disease  of,  Paget's,  512,  531 

supernumerary,  532 
Nitze  apparatus,  363 
Noble,  G.  H.,  276,  282,  285,  350,  356 
Noble's  operation,  350 
Nodular  goiter,  602 


A. 


Noma,  560 
Non-union,  852,  853 
Nothnagel,  48,  154 
Nuck,  canal  of,  280,  330 


Obstruction,  intestinal,  47,  182 
acute,  48 

diagnosis  of,  50 
pathologj'  of,  49 
chronic,  53,  68 

symptoms  of,  53,  68 
treatment  of,  54 
pyloric,  128,  139 
treatment  of,  140 
Obturator,  192 
Occlusion  of  rectum,  90 
Ochsner,  A.  J.,  35,  214,  229,  230 

treatment,  36 
Odiorne,  Walter  B.,  464 
Odontoma,  561,  840 

follicular,  562 
0'D^^•yer,  579 

intubation,  580 
Omentum,  diseases  of,  87 

injuries  of,  87 
Oophorectomy,  338 
Optic  neuritis,  641 
Orchidectomy,  427,  428,  470 
OrcWtis,  468 

Organic    head    lesions,    symptoms    and 
diagnosis  of,  634 
lesions,  symptomatology  of,  641 
stricture,  455 

treatment  of,  456 
Orthopedic  surgery,  943 
Os  calcis,  916 

Osgood,  Robert  B.,  812,  959 
Osier,  William,  65,  67,  154,  190,  224,  227 
Osteitis  deformans,  953 
Osteogenesis  imperfecta,  952 
Osteoma,  828 
Osteomalacia,  952 
Osteomyelitis,  559 
acute,  946 
chronic,  948 
Osteoplastic  craniotomy,  663 

resection  of  spine,  693 
Osteopsathyrosis,  952 
Osteosarcoma,  832 
Otis's  dilating  urethrotome,  457 

urethrometer,  457 
Outerbridge,  351 
Ovarian  cyst,  334 
twisted,  336 
tumor,  symptoms  of,  336 

comphcating  pregnancy,  339,  341 
Ovaries,  319,  331 
hematoma  of,  336 

operations  on  tubes  and,  conservative, 
329,  332 
1      papilloma  of,  335 
tumors  of,  solid,  336 
Ovariotomy,  333,  338 
Ovaritis,  322,  331 
I      acute,  332 


1008 


IXDKX 


Ovaritis,  chronic,  332 

tulHTculous,  332 
Ovula  Xal)otlii,  269 


Pacchionian  f^ranulationw,  043 

Pacliynieninjjitis,  047 

Paget,  Sir  James,  197,  198,  227,  953 

Paget 's  disease  of  nipple,  50S,  512,  531 

Painter,  C.  ¥.,  240,  S12 

Palmar  abscess,  745,  749 

Brooks'  incision  for,  751 
Pamijiniform  plexus,  331 
Pancreas,  181 

cysts  of,  185,  186 

sclerosis  of,  182 

tumors  of,  184 
Pancreatic  apoplexy,  181,  183 

calculi,  1§3,  184 

ducts,  169 
Pancreatitis,  128,  181,  182,  183 

acute,  181 

chronic,  181,  183 

sub-acute,  183 
Papillary  cystadenoma,  526 
Pajiilloma,  106,  838 

of  ovaries,  335 

of  rectum,  100 

villous,  839 
Paralysis,  facial,  712 

musculospiral,  710 
Paranephritic  abscess,  379 
Paraphimosis,  439,  440 
Parasitic  theory  of  cancer,  820 
Parathyroid  glandules,  597,  598,  599,  008 

tumors,  01 1 
Para-urethral  abscess,  452 
Pare,  Ambroise,  490,  031,  070,  734,  772 
Park,  Roswell,  777,  778,  818,  825,  830, 

943,  955,  990 
Parker,  Willard,  17 
Paronychia,  745,  748,  749 
Parotid  gland,  chondroma  of,  575 

excision  of,  575 
Patella,  dislocation  of,  939 

fracture  of,  904 

operation  on,  900 
Patellae  ligamentum,  808 
Pathologic  fracture,  854,  924 
Paul  of  Egina,  070 
Payr,  008 
P^an,  127 

Pediculi  capitis,  594 
Pelvic  hematocele,  341,  344 

viscera,  anatomy  of,  255 
Peh-is,  fracture  of,  802 
Penis,  433 

amputation  of,  451 

cancer  of,  450 

injuries  of,  447 
Pennington,  J.  R.,  93 
Penski,  163 
Peptic  ulcer,  129,  133 
of  esophagus,  127 

treatment  of,  133 
perforating,  142 


Perforation,  intestinal,  05 

of  uterus,  275 

symptoms  of,  65 

typhoid,  64 
Pericardial  effusions,  497 
Pericardiotomy,  498 
Pericarditis,  497 
Pericardium,  490 

operations  upon,  497 
Periductal  connective  tissue,  522 

fibroma  of  Ijreast,  524 

myxoma,  524,  525 

sarcoma,  524 
Perigastritis,  128 
Perineal  lacerations,  345 

lithotomy,  404 

prostatectomy,  420,  423,  426 

section,  454 

urethrotomy,  453 
Perineum,  345 

muscles  of,  258 

operation  for  repair  of,  346 
Perineuritis,  095 
Periosteal  fracture,  854 
Periostitis,  945 
Peripheral  nerves,  094 
Perithelioma,  835 
Peritoneum,  223 

teratoma  of,  242 
Peritonitis,  28,  49,  73,  182,  186 

acute,  223 

circumscribed,  49 
diffuse,  49 

chronic,  234 

adhesive,  sclerosing,  235 

diffuse,  28,  225,  228 
symptoms  of,  226 
treatment  of  228 

exudative,  234 

general,  225,  228 

hysteric,  227 

idiopathic,  225 

localized,  224 

malignant,  238 

sources  of,  226 

subphrenic,  224 

tuberculous,  236 
operation  for,  238 
Peroneal  nerve,  716 
Pessary,  279,  285,  289 
Peters,  389 
Petersen,  W.  P.,  107 
Pfannensteil,  282 
Phalanges,  895 

of  foot,  917 

fracture  of,  895 
Phalanx  of  thumb,   dislocation  of  first, 

934 
Phantom  tumor,  76 
Pharynx,  570 
Phelps,  212 
Phimosis,  439 
Phlebitis,  773 

obliterans,  773 
Phlegmasia  alba  dolens,  772 
Phloridzin  test,  305 


INDEX 


1009 


Phosphorus  necrosis,  569 
rhrcnii'  ncrvo,  713 
I'ia  mater,  ()43 
Piles,  W,  100 

straufiuhited,  100 
Pin  worms,  03 
Piropioff's  ojieration,  9^3 
Pituitary  body,  (J57 
Plastic  operations  on  face,  544 

resection  of  breast,  527 
Playfair,  318 
Pleura,  4SS 

echinococcus  of,  495 
tumors  of,  495 
Pleurisy,  489  . 

Pleuro-peritoneal  cavity,  194 
Plexiform  angioma,  776 
Plummer,  119 
Pneumatic  suit,  770,  977 
Pneumogastric  nerve,  713 
Pneumonia  inhalation,  584 
Pneumonotomy,  481 
Polk,  329 
Polypi,  271 
in  uterus,  293 
mucous,  106,  269 
Ponfick,  162 
Porro's  operation,  305 
Portal  circulation,  73 

vein,  169 
Porter,  Charles  Allen,  71,  767 
Porter,  Charles  Burnham,  17 
"Port-wine  stain,"  556 
Postenski,  212 
Posteriortibial  art-eiy,  780 
urethritis,  440 

wire  spUnt,  Cabot  (A.  T.),  910 
Posthitis,  439 
Posture,  knee-chest,  111 
Pott,  Percival,  7^9,  913 
Pott's  fracture  of  fibula,  913 
Poultices,  746 
Pt3wder,  face,  545 
Powers,  Charles  A.,  Ill,  189 
Precancerous  conditions,  845 
Pregnancy,  abdominal,  341 
extra-uterine,  340,  341 
ovarian,  341 
tubal,  340 
Prepatellar  bursitis,  809 
Probang,  114 
Procidentia  uteri,  277,  288,  349 

treatment  of,  289 
Proctitis,  93, 
Proctoclysis,  234,  770 
Proctoplasty,  92,  105 
Proctoscope,  90,  93,  104 
Proctotomy,  104,  105 
Prolapse  of  anus,  102 
of  rectum,  103 
of  spleen,  187 
of  stomach,  245 
of  uterus,  288 
Prostate,  388,  411 
anatomy  of,  411 
calculi  of,  414 

64 


Prostate,  cancer  of,  415,  428 
excision  of,  429,  430 
enlarged,  390,  415 

sym])t()ms  of,  41() 
inflamnuition  of,  412 
massage  of,  413,  444 
sarcoma  of,  432 
Prostatectomy,  perineal,  420,  423,  426 

suprapubic,  416,  420,  421 
Prostatitis,  acute,  439 
chronic,  414 
treatment  of,  413 
tulserculous,  414 
Proud  flesh,  741 
Pruritus  ani,  93 
Psammoma,  828 
Pseudocyst,  185,  186 
Psychic  aspects  of  Graves'  disease,  bOl 
Psychoses,  662 
Pterion,  637 
Ptosis,  128 

abdominal,  243 

bandage  for,  166 
gastric,  61 
of  liver,  62 
visceral,  63 
Pulmonary  actinomycosis,  486 

tuberculosis,  485 
Puncture  of  bladder,  suprapubic,  394 

lumbar,  648 
Punctured  fracture,  622 
Purmann,  772 
Putnam,  James  J.,  699 
Pyelitis,  375,  378 
Pylorectomy,  127,  140,  149 
Pyloric  obstruction,  128,  139 
I      stenosis,  131,  145 

hypertropliic,  145 
in  infants,  129,  141 
Pyloroplasty,  Finney's,  134,  140 
Pylorus,  spasm  of,  129,  144 
Pyonephrosis,  377 
Pyopneumothorax,  131,  224 
Pyosalpinx,  320 
Pyothorax,  490 


QuiMBY,  W.  C,  71,  438 
Quincke,  648 

Radial  arteiy,  780 

Radius,  head  of,  dislocation  of   933 

head  and  neck  of,  fracture  of,  88b 

neck  of,  fracture  of,  881 
Ranula,  547,  823 
Pawling,  L.  B.,  626 
Rectal  lymphatics,  109 

tenesmus,  79 

valves,  hypertrophy  of,  90 
Rectocele,  346,  347 
Rectopexy,  104  c   of:a 

Rectovaginal  fistula,  353,  355,  356 
Rectum,  cancer  of,  106,  107 

imperforate,  90 

inflammation  of,  92 


1010 


INDEX 


Rectum,  iiiflainmation  of,  gonorrheal,  93 
occlusion  of,  90 
papilloma  of,  lOti 
proluj).sc  of,  103 
resection  of,  109 
anal  nicthotl,  109 
conihinod,  1 10 
dorsal,  110 
sacral,  1 10 
stricture  of,  104 
sypliilitic  affection  ot,  94 
tuberculosis  of,  94 
tumors  of,  106 
ulcer  of,  93 
Reed,  351,  935 
Regeneration  of  nerves,  707 
Reichmann's  disease,  144 
Reinlmch,  99 
Renal  calculi,  370 

treatment  of,  381,  382 
disease,  diagnosis  in,  360 
Resection  of  breast,  plastic,  527 
of  jaw,  upper,  565 
of  jaws,  upper  and  lower,  564 
of  rectum,  combined  method,  110 
dorsal  method,  110 
sacral  method,  110 
of  ribs,  491 
of  sigmoitl,  80 
of  sj)ine,  osteoplastic,  693 
Retention  cysts,  820 
of  breast,  532 
of  urine,  389,  390 
Retrocecal  fossa,  76 
Retroduodenal  fossa,  76 
Retroflexion  of  uterus,  284,  285 
Retroperitoneal  cysts,  241 
hernia,  193 

lymph  nodes,  tuberculosis  of,  239 
space,  238 

tumors  of,  241 
Retroversion  of  uterus,  276 

treatment  of,  279 
Reynolds,  Edward,  241,  329,  345 
Rhinoplasty,  545 

f'odman's  (E.  A.),  546 
Rhinorrliea,  cerebrospinal,  645 
Rib,  cervical,  597 
fracture  of,  859 
resection  of,  491 
Ribbert,  21 
Richardson,  Maurice  Howe,  17,  93,  122, 

123,  124,  190,  338 
Rickets,  951 
Ricketts,  B.  M.,  481 
Ricord,  PhilUpe,  434 
Ridlon,  898 
Riebold,  122 
Riedel's  lobe,  167 
Riva-Rocci  apparatus,  721 
Robinson,  Samuel,  894 
Robson,  Mayo,  184 
Robson's  point,  169 
Rodent  ulcer,  554,  618 
Rogers,  John,  601 
Rokitansky,  75,  960 


Rolando,  fissure  of,  638 
Rosary,  951 
Rose,  543 

position,  584 
Rotcii,  Thomas  Morgan,  240 
Rotter,  212,  514 
Roux,  140,  141,  534,  605 

operation,  complete,  140 
Russell,  R.  Hamilton,  194 
Rutkowski,  389 
Rydygier,  127,  167,  191,  355 


Sacculation  of  bladder,  408 
Sactosalpinx  hemorrhagica,  320 
purulenta,  320 
serosa,  320 
Safety-pin,  56,  92 
SaUne  infusion,  771 
Salivary  fistula,  547 

glands,  574 

stone,  547 
Salpingectomy,  326 
Salpingitis,  319 

catarriial,  319,  325 

purulent,  319 

symptoms  of,  322 

treatment  of,  325 

tuberculous,  320,  322,  324 
Sampson,  Jolm  A.,  315,  316 
Sandelin's  cheiloplasty,  552 
Sanger,  318,  355 
Santorini,  duct  of,  169,  181 
Sarcoma,  829 

giant-cell,  832 

of  breast,  periductal,  524 

of  esophagus,  125 

of  intestines,  77 

of  jaw,  563 

of  kichiey,  384 

of  lung,  486 

of  prostate,  432 

of  stomach,  153 

of  testicle,  476 

of  tongue,  574 

of  uterus,  317 
Sargent,  Percy  W.  G.,  197 
Sausage-shaped  tumor,  74 
Savoiy,  William  S.,  767 
Scalp,  avulsion  of,  616 

closing,  Cushing's  method  of,  667 

contusion  of,  614 

cysts  of,  dermoid,  617 

hematoma  of,  615 

neurofibroma  of,  617 

tumors  of,  616 

wounds  of,  615 
Scannell,  David  D.,  233,  854 
Scai)hoid,  fracture  of,  892 
Scapula,  fracture  of,  867 
Scars,  malignant  degeneration  of,  817 
Scliandinn,  444 
Scliede,  212,  372 

Scliede's  operation,  482,  493,  494,  775 
Scheele,  369 
Schiassi's  operation,  165 


INDEX 


1011 


Schimmplbusch,  M5 

Schiuii'dcu,  N'ictor,  7!)4,  795 

Schroder,  270,  :i2\) 

Schroder's  operation,  270 

Schulz,  495 

Schwann,  sheath  of,  671 

Sclerosis  of  pancreas,  182 

Sciatica,  705 

Sciatic  hernia,  192 

Scrotal  hernia,  192 

Scudder,  Charles  L.,  141,  207,  208,  209, 

251,  408,  477,  850,  856,  859,  862,  864- 

866,  868,  869,  871-878,  880,  882-885, 

888-892,  894,  895,  898,  900-902,  904, 

909-919,  921,  922,  926,  928,  929-933, 

936,  941 
Section,  perineal,  454 
Seelig,  M.  G.,  41,  125 
Seeping  method,  40,  234 
Semilunar  cartilage,  940 
Senn,  Nicholas,  188 
Sequestrum,  945 
Serous  meningitis,  681 
Serum,  horse,  814 
Shattuck,  Frederick,  C,  237 
Sheath  of  Schwann,  671 
Sheen,  768 
Sheldon,  John  G.,  37 
Sherrington,  638 
Shipton,  42 
Shock,  767,  976 

diagnosis  of,  769 

treatment  of,  769,  772 
Shoulder,  dislocation  of,  927 

old  unreduced,  931 
Shoulder-joint  amputation,  991 
Sigmoid  flexure,  diverticula  of,  59 

resection  of,  80 
Sigmoidopexy,  104 
"Silver-fork"  deformity,  886 
Simon,  358,  389,  536 
Simmons,  Channing  C,  464 
Sims,  Marion,  353 
Sims'  position,  354 

speculum,  354 
Singley,  J.  D.  V.,  543 
Sinus  thrombosis,  646 

tuberculous,  503 
Skin,  812   _ 

disinfecting,  725 
Skull,  619 

fracture  of,  620 

opening,  664 
Small,  E.  H.,  91 
Smith,  H.  L.,  880 
Smith,  Nathan,  338 
Smith,  Stephen,  985 
Smith,  WilUam  H.,  237 
Smyth,  A.  W.,  777 
Sobotta,  193,  239,  258 
Society  of  Clinical  Surgery,  Frontispiece 

and  71 
Sounding  for  stone,  399 
Sounds,  bulbous,  113 

Schreiber's  dilating,  114 
'  Starck's  diverticulum,  114 


Spasm,  facial,  712 

of  i)yl()rus,  129,  144 
Spasmodic  stricture  of  urethra,  454 

torticollis,  587,  588,  713 
Spasticity,  642 
Spear,  Walter  M.,  188 
Spermatocele,  471,  474 
Spiller,  William  G.,  613,  709 
Spina  bifida,  681,  ()82,  683,  684 
Spinal  meningitis,  680 
Spine,  613,  669 

concussion  of,  674 

contusion  of,  674 

"railway,"  674 

resection  of,  osteoplastic,  693 

tumors  of,  685 
Spinofacial  anastomosis,  711 
Spiral  fracture,  854 
Splanchnoptosis,  243 
Spleen,  187 

abscess  of,  188 

cysts  of,  188 

pathologic,  187 

prolapse  of,  187 

ptosis  of,  190 

rupture  of,  187 

tuberculosis  of,  188 

wandering,  191,  250 

wounds  of,  187 
Splenectomy,  187,  188,  189,  190,  191 
Splenic  anemia,  190,  799  ' 

enlargement,  189 

leukemia,  myelogenous,  191 
Splenomegaly,  190 
Splenopexy,  191 

Rydygier's,  167 
Splenoptosis,  243 
Splint,  Cabot's  posterior  wire,  910 

Cobb's,  918 

CooUdge's,  918 

Desault,  913 

Dupuytren's,  915 

Matas,  922 

Thomas  hip,  898 
Splints,  applying,  731 

types  of,  855 
Spondylitis  deformans,  972 
"Spotted  fever,"  648 
Sprain,  956 

"Stab  wound,"  177,  178 
Staffordshire  knot,  339 
Starr,  M.  Allen,  613 
Steno's  duct,  547 
Stenosis,  intestinal,  69 

of  pylorus,  131,  145 
hypertrophic,  145 
in  infants,  129 
Sternum,  fracture  of,  861 
Stewart,  695 

Stimson,  L.  A.,  859,  932,  937 
Stinson,  J.  Coplin,  461 
Stinson's  operation  for  hypospadias,  460 
Stomach,  113,  127,  168 

cancer  of,  145 

distortion  of,  129,  131,  142 

hour-glass,  129,  131,  142 


1012 


INDEX 


Stomach,  lymphatics  of,  146 

prolapse  of,  243 

sarcoma  of,  I5'.i 

wounds  of,  154 
Stone,  Arthur  K.,  184,  243 
Stone  in  bladder,  398 

in  kidney,  3G9 

salivarj',  .")47 

sounding  for,  399 
Storer,  Malcolm,  32(1,  329,  337,  340 
Strangulated  hernia,  19G,  197,  198 

piles,  100 
Strangulation,  intestinal,  50,  51 
Streptothrix,  70 
Stricture,  acquired,  454 

inflan^matorj-,  455 

of  esophagus,  114,  115 
diagnosis  of,  118 
treatment  of,  118 

of  rectum,  104 

organic,  455 

spasmodic,  454 

traumatic,  452 

urethral,  452 
Struma,  602 
Strumpell,  652 
Study  of  cases,  719 
Stump,  ners-e  anastomosis  in,  710 

painful,  980 
Subdeltoid  bursa,  808 
Subdural  hemorrhage,  628 
Subinvolution  of  uterus,  268 
Suboccipital  exploration,  667 
Summers,  J.  E.,  190 
Suppurative  leptomeningitis,  648 

meningitis,  680 
urotropin  in,  649 
Supracondyloid  fracture  of  femur,  903 
Suprapatellar  bursa,  808 
Suprapul)ic  cystotomy,  402 

prostatectomy,  -416,  420,  421 
Suprarenal  gland,  382 

tumors  of,  386 
Surgical  kidnev,  376,  377,  378 
Sutclitfe,  W.  G.,  592 
Suture  of  blood-vessels,  792 

of  nerves,  707,  708 
Sylvius,  fissure  of,  638 
Syme's  operation,  982 
Synovitis,  956 
Syphilis,  434 

genital  lesions  of,  444 

of  anus,  94 

of  bone,  949 

of  breast,  531 

of  liver,  160 

of  rectum,  94 
Syphilitic  epididymitis,  468 

orchiditis,  468 
Syringomyelocele,  681,  682 


Tait,  Law-son,  297,  347,  356 

operation,  356 
Talma,  163,  164,  167 
Tape,  absorbent,  733 


Taxis,  185 

Tavlor,  Alfretl  S.,  539 
Taylor,  K.  W.,  690 
Teale's  amputation,  986 
Tendon,  801,  S03 

conjoined,  206 

slieaths,  tumors  of,  806 

transplantation,  808 

wouiuls,  S06 
Tendoplasty,  807 
Tenesmus,  rectal,  79 
Tenosynovitis,  804 

tuberculous,  805 
Teratoma,  824 

of  peritoneum,  242 

of  testicle,  476 
Terrier,  64,  165 
Testicles,  absence  of,  467 

adenoma  of,  476 

cancer  of,  476 

cysts  of,  dermoid,  476 

inflammation  of,  468 

sarcoma  of,  476 

tuberculosis  of,  469 

tumors  of,  475 

xmdescended,  464 

wounds  of,  468 
Tetany,  gastric,  129,  144 
Thecitis,  804 

Therapeutics,  mechanical,  795 
Thigh,  fracture  of,  903 
Thomas  collar,  123 

hip  splint,  898 
Thompson,  George,  141,  363 
Thompson,  Heniy,  366 
Thoracentesis,  48*9 
Thoracic  duct,  wounds  of,  593 
Thomdike,  Paul,  384 
Three-glass  test,  441 
Thrombosis,  mesenteric,  71 

sinus,  646 
Thumb,   dislocation  of  first   phalanx  of, 

934 
Thyroglossal  cysts  and  ducts,  548 
Thyroid,  accessor^-,  598 

fracture  of,  579 

glantl,  597 

cancer  of,  610 
inflammation  of,  611 
Thyroidectomy,  607 
Thyrotoxic  disease,  599,  600 
Tibia,  rupture  of  tubercle  of,  908 
Tibial  arten,%  anterior,  782 

posterior,  780 
Tic  douloureux,  698 

convulsive,  712 
Tileston,  Wilder,  127,  164 
Tillmanns,  162,  624 
Toe-nail,  ingrowing,  758 

packing,  760 
Toes,  amputation  of,  981 
Toldt,  671 
Tongue,  569 

abscess  of,  571 

cancer  of,  571 

operation  for,  572 


INDEX 


1013 


Toiiiiiie,  infl;iiniii;itii)n  of,  .")7() 

sarcoma  of,  .")7  I 

tie,  570 

tuhorculosis  of,  .■>71 

tmnoi-s  of,  non-malii^naut,  574 

wounds  of,  '■>70 
Tonsil,  tvimors  of,  570 
Torticollis,  .'jSC) 

spasmotlic,  587,  588,  713 
Toxins  of  eiysipelas,  848 
Trachea,  foreign  boily  in,  579 
Transfusion  of  blooil,  368 
Transposition  of  viscera,  5i) 
Traumatic  aspliyxia,  502 

bursitis,  treatment  of,  809 

neurosis,  674 

stricture,  452 
Treitz,  ligament  of,  135 
Trendelenlnirg,  F.,  212,  774 

position,  195,  207,  256,  355 
Treves,  Frederick,  76,  614 
Trichina  spiralis,  803 
Trichiniasis,  803 
Trifacial  neurectomy,  700 
Truss,  203,  204 
TiTpsin  treatment,  848 
Tubal  abortion,  340,  341 

pregnancy,  340 

rupture,  340,  341,  342 
Tube,  Einhorn-Jackson-Mosher,  116 

Symoiid's  esophageal,  110 

T-,  324 
Tuberculosis,  ileocecal,  69 

of  anus,  94 

of  bone,  948 

of  burs£e,  812 

of  intestines,  67 

of  joints,  960 

of  kidney,  380 

of  retroperitoneal  lymph  nodes,  239 

of  rectum,  94 

of  spleen,  188 

of  testicle,  469 

of  tongue,  571 

pulmonary,  485 

renal,  381,  382 
Tuberculous  adenitis,  treatment  of,  591 

cystitis,  395 

disease  of  breast,  531 

ganglion,  806 

lympli  nodes,  799 

ovaritis,  332 

peritonitis,  236,  238 

prostatitis,  414 

salpingitis,  320,  323,  324  . 

sinuses,  503 

tenosynovitis,  805 

ulcers,  58 
Tubular  diarrhea,  63 
Tulndocysts,  820 
Tumors,  benign,  818 

causation  of,  819 

cavernous,  776 

cerebellar,  656 

connective-tissue,  826 

epithelial,  838 


Tumors,  fecal,  57 
intracranial,  ()54 
intramedullary,  689 
intraspinal,  laminectomy  for,  694 
malignant,  8 IN 
meningeal,  650,  686 
of  alxlominal  wall,  252 
of  anus,  105 
of  bladder,  405 

diagnosis  of,  406 
of  brain,  (553 

sym])toms  of,  655 

treatment  of,  657 
of  breast,  ^^'arren's  classification  of,  523 
of  broad  ligament,  330 
of  bursEP,  812 
of  cauda  equina,  689 
of  chest-wall,  504 
of  conus  medullaris,  689 
of  cranial  bones,  650 
of  esophagus,  125 
of  face,  556 

of  Fallopian  tubes,  329 
of  intestines,  76 

benign,  77 
of  jaw,  561 
of  kidney,  382 

cystic,  385 
of  larynx,  583 
of  Hver,  159 

treatment  of,  161 
of  pancreas,  184 
of  pleura,  495 

of  retroperitoneal  space,  241 
of  rectum,  106 
of  scalp,  616 
of  spine,  685 
of  suprarenal  gland,  386 
of  tendon-sheaths,  806 
of  testicle,  475 
of  tongue,  574 
of  tonsil,  576 
of  umbilicus,  254 
of  uterus,  292 
ovarian,  complicating  pregnancy,  339 

solid,  336 

symptoms  of,  336 
parathyroid,  611 
phantom,  76 

round  ligaments,  soUd,  331 
sausage-shaped,  74 
Tunica  vaginalis,  hydrocele  of,  471 
Tuttle,  102 
Twisted  cord,  477 


Ulcer,  acute,  129,  130 
chronic,  129,  130 
duodenal,  30,  129,  130,  131,  133,  144, 

173 
malignant  degeneration  of,  817 
Marjolin's,  817 
of  bladder.  404 

treatment  of,  405 
of  esophagus,  127 

peptic,  127 


1014 


INDEX 


I'lcer  of  leg,  742 

of  rectum,  93 

peptic,  128,  129,  130,  133 
perforating,  142 

rodent,  554,  618 

varicose,  740,  742 
T'ltzmann's  syringe,  437 
I'nihilicus,  inflammations  about,  254 

malformations  of,  253 

tumors  of,  254 
Upper  extremity  (shoulder  girdle),  am- 
putation of,  989 

jaw,  fracture  of,  920 
I' radius,  malformations  of,  253 
Ureteral  calculi,  371,  373 

catheter,  364 
Ureter,  359 

and  cervix  uteri,  relations  of,  259 

double,  360 

injuiy  of,  375 

kinking  of,  375 
Urethra,  433 

anatomy  of,  433 

calculus  of,  452 

foreign  body  in,  451 

stricture  of,  452 
Urethral  caruncle,  352 

fistula,  458 
Urethritis,  non-specific,  435 

posterior,  440 
Urethrometer,  Otis's,  457 
Urethroscopy,  458 
Urethrotome,  Otis's  dilating,  457 
Urethrotomy,  perineal,  453 
Urethrovaginal  fistula,  353,  354 
Urinaiy  calculi,  symptoms  of,  370 
Urine,  incontinence  of,  397 

residual,  417 

retention  of,  397 

segregating,  364 
Urotropin,  667 

in  suppurative  meningitis,  649 
Uterosacral  ligaments,  279 
Uterus,  255 

adenocarcinoma  of,  306 

anteflexion  of,  285 

Dudley's  operation  for,  286 

anteversion  of,  276,  284 

cancer  of,  305 
diagnosis  of,  309 
symptoms  of,  308 
treatment  of,  309 
pan-hysterectomy  for,  317 

deciduoma    malignum    (choriodecidu- 
oma),  318 

descent  of,  288 

displacements  of,  275 

endothelioma  of,  317 

inflammations  of,  261 

lacerations  of,  272 

lymphatic  connections  of,  257,  260 

myoma  of,  symptoms  of,  293 
treatment  of,  296 

perforation  of,  275 

polypi  in,  293 

procidentia  of,  277,  288,  289,  290 


Uterus,  retroflexion  of,  284,  285 
retroversion  of,  276 
sarcoma  of,  317 
steaming,  297 
subinvolution  of,  268 
suspension  of,  280 

through  abdominal  section,  281 

through  vagina,  281 
tumors  of,  292 
wounds  of,  274 


Vaccine  therapy,  251 
Vagina,  atresia  of,  357 
^'aginal  cysts,  357 

fistula,  353 

process,  194 
Vaginitis,  357 
Valve  of  Gerlach,  18,  20 
Valvulse  conniventes,  43,  44 
Vander  Veer,  Albert,  821 
van  Hook,  375 
van  Kaathoven,  709 
van  Zwalenburg,  ('.,  21 
Varices,  99 

Ijinph,  796 
Varicocele,  474 

of  broad  ligament,  331 
Varicose  aneurj-sm,  776 

iilcer,  740,  742 

veins,  774 
Varix,  aneuiysmal,  776,  784,  791 
Vasa  recta,  45 
Vasectomy,  427 
Vaughan,  George  T.,  500 
Vein  enucleator,  Mayo's,  775 

portal,  169 
Venereal  warts,  448,  762 
Ventral  hernia,  192 
Ventrofixation,  290 
Ventrosuspension,  290 
"N'erruca,  448 

acuminata,  761 

filiformis,  761 

senilis,  761 

vulgaris,  761 
Vertebrae,  dislocation  of,  676 

fracture  of,  676 
Verumontanum,  434 
Vesico-uterine  fistula,  353 
Vesico-utero vaginal  fistula,  353 
Vesicovaginal  fistula,  353,  354,  355 
Vessels,  lymjjh,  796 
Villous  papilloma,  839 
Vincent,  Beth,  25 
Virchow,  60,  243,  505,  960 
Viscera,  pelvic,  anatomj'  of,  255 

transposition  of,  59 
Visceral  ptosis,  63 
Vitello-intestinal  duct,  57,  253 
Volkmann's  contracture,  801,  802 
Volvulus,  73,  75 
Vomit  us,  coffee-ground,  132 
von  Bergmann,  212,  225,  625,  630 
von  Dittel.  355 
von  Eiciien,  479 


INDEX 


1015 


von  Graefe,  534 
von  }l:ill(>r,  ,V.)5 
von  J.;in,<;('ul)('ck,  fy',M],  543 
von  Mikulicz,  7<S,  SO,  SI,   S2,    114,    115, 
120,  121,  127,  145,  225,  22S,  (iOS,    978 
von  Kecklinijjhauson,  i)54 
von  liccklingluivisen's  disease,  G17 
von  "\yink(4,  355 
Vulpius,  S07 


Wagner,  E.,  495 

Walcher,  355 

Waldeyer,  613 

Walker,  George,  385,  470 

Waller  694 

Walton,  G.  L.,  587,  613,  678 

Wardrop  method,  791 

operation,  787 
Warren,  J.  Collins,  505,  506,  514,  515,  523, 

534,  576,  842 
Warren,  John  C,  218,  534 
Warren  Museum  (Harvard),  58,  129,  376, 

380,  507,  508,  509,  510,  511,  631 
Warren's    (J.    Collins)    classification    of 
breast  tumors,  523 

operation  for  amputation  of  the  breast, 
576 
Warthin,  799 
Warts,  757,  761 

venereal,  448,  762 
Waterman,  G.  A.,  699 
Watson,  Francis  S.,  368,  405,  407,  408, 

411,  420,  423,  584 
Weichselbaum,  648 
Weir,  Robert  F.,  64,  112 
Wells,  Spencer,  237,  339 
Wen,  616 
Wetherill,  235 
Wharton's  duct,  547 
White,  James  C,  445 
Whitehead's  operation,  102 

for  cancer  of  tongue,  572 
Whitlow,  745 
Whitman's  method,  898 
Whitney,  W.  F.,  527 
Wilson,  H.  Augustus,  808,  899 
Winslow,  foramen  of,  76 


Wirsung's  duct,  181,  182,  183,  184 

Witzcl,  417 

Witzel's  gastrostomy,  64,  152,  212 

Wolbarst,  A.  L.,  475 

Wolff  grafts,  815 

Wolffian  ducts,  319 

Wolfler,  81,  127,  212 

Wood,  154 

WooLsey,  George,  21,  681,  695,  706,    714, 

715 
Wounds,  granulating,  740 

incised,  724 

lacerated,  732 

of  abdomen,  penetrating,  55 

of  bladder,  gunshot,  410 

of  brain,  630 

of  cord,  675 

of  heart,  497 

of  joints,  734 

of  kidney,  368 

of  nerves,  710 

of  scalp,  615 

of  spleen,  187 

of  stomach,  154 

of  tendons,  806 

of  testicle,  468 

of  thoracic  duct,  593 

of  tongue,  570 

of  uterus,  274 
Wright,  A.  E.,  591 
Wright,  James  Homer,  69,  70 
Wrist,  disarticulation  of,  991 

dislocation  of,  934 
Wrist-drop,  716 
Wrist-joint,  excision  of,  965 
Wry-neck,  586,  713 
Wyeth,  John  A.,  987,  988 

Yale,  338 

Young,  Hugh  H.,  412,  415,  420,  423,  428. 
429 

Zander,  795 

treatment,  766 
Zanfel,  647 
Zondek,  373 
Zuckerkandl,  21 


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DISEASES   OF   THE  EYE. 


DeSchweinitz's 
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Recently  Issued — The  New  (6th)  Edition 

Diseases  of  the  Eye:  A  Handbook  of  Ophthalmic  Practice. 
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Medical  School." 

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Brtihl,  Politzer,  and  Smith's 
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Haab  and  deSchweinitz*s 
Operative  Ophthalmology 

Atlas  and   Epitome  of    Operative    Ophthalmology.       By  Dr.  O. 

Haab,  of  Zurich.  P^dited,  with  additions,  by  G.  K.  de  Schweinitz, 
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DISEASES   OF   THE  EYE. 


Haab  and  DeSchweinitz*s 
External  Diseases  qf  the  Eye 


Atlas  and  Epitome  of  External  Diseases  of  the  Eye.     By  Dr.  O. 

Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  deSchweinitz, 
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THE   NEW    (3d)    EDITION 

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Haab  and  DeSchweinitzV 
Ophthalmoscopy 


Atlas  and  Epitome  of  Ophthalmoscopy  and  Ophthalmoscopic 
Diagnosis.  By  Dr.  O.  Haab,  of  Zurich.  Edited,  with  additions,  by 
G.  E.  deSchweinitz,  M.  D.,  Professor  of  Ophthalmology,  University 
of  Pennsylvania.  With  152  colored  lithographic  illustrations  and  92 
pages  of  text.     Cloth,  ;^3.oo  net.     Li  Saunders'  Hand-Atlas  Series. 

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scopic Diagnosis  has  been  fully  established  and  entirely  justified  an  English 
translation.  Not  only  is  the  student  made  acquainted  with  carefully  prepared 
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The  Lancet,  London 

"We  recommend  it  as  a  work  that  should  be  in  the  ophthalmic  wards  or  in  the  library  of 
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S.nWDERS'   BOOKS  OX 


Gradle*s 
Nose,  Pharynx,  and  Ear 

Diseases  of  the  Nose,  Pharynx,  and  Ear.  By  Henry  Gradle, 
M.  D.,  Professor  of  Ophthalmology  and  Otology,  Northwestern  Uni- 
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INCLUDING  TOPOGRAPHIC  ANATOMY 

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Topographic  anatomy  has  been  accorded  liberal  space. 

Pennsylvania  Medic&I  Journal 

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Kyle's 
Diseases  of  Nose  and  Throat 


Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D., 
Professor  of  Laryngology  in  the  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  797  pages;  with  219  illustrations,  26  in  colors. 
Cloth,  54.00  net;  Half  Morocco,  ^5.50  net. 

THE    NEW    (4th)    EDITION 

Four  large  editions  of  this  excellent  work  fully  testify  to  its  practical  value. 
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down  to  date.  With  the  practical  purpose  of  the  book  in  mind,  extended  con- 
sideration has  been  given  to  treatment,  each  disease  being  considered  in  full,  and 
definite  courses  being  laid  down  to  meet  special  conditions  and  symptoms. 
Pennsylvania  Medical  Journal 

"  Dr.  Kyle's  crisp,  terse  diction  has  enabled  the  inclusion  of  all  needful  nose  and  throat 
knowledge  in  this  book.  The  practical  man,  be  he  special  or  general,  will  not  search  in  vain 
for  anything  he  needs." 


y-; ]'/';,  ear,  nose,  and  throat. 


GET  i^ •  THE  NEW 

THE  BEST         /»  111  6  X  1  C  Ci  11         STANDARD 

Illustrated   Dictionary 

The  New  (5th)  Edition 


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"Dr.  Dorland's  Dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
size.     No  errors  have  been  found  in  my  use  of  it." 

Theobald*s  Prevalent  Eye  Diseases 


Prevalent  Diseases  of  the  Eye.  By  Samuel  Theobald,  M.  D., 
Clinical  Professor  of  Ophthalmology  and  Otology,  Johns  Hopkins 
University.  Octavo  of  5 50  pages,  with  219  text-cuts  and  several  colored 
plates.     Cloth,  ^4.50  net ;  Half  Morocco,  ^6.00  net. 

THE    PRACTITIONER'S    OPHTHALMOLOGY 

With  few  exceptions  all  the  works  on  diseases  of  the  eye,  although  written 
ostensibly  for  the  general  practitioner,  are  in  reality  adapted  only  to  the  specialist  ; 
but  Dr.  Theobald  in  his  book  has  described  very  clearly  and  in  detail  those  condi- 
tions, the  diagnosis  and  treatment  of  which  come  within  the  province  of  the  general 
practitioner.  The  therapeutic  suggestions  are  concise,  unequivocal,  and  specific. 
It  is  the  one  work  on  the  Eye  written  particularly  for  the  general  practitioner, 

Charles  A.  Oliver,  M.D., 

Clinical  Professor  of  Ophthalmology,   Woman  s  Medical  College  of  Pennsylvania. 

"  I  feel  I  can  conscientiously  recommend  it,  not  only  to  the  general  physician  and  medical 
student,  for  whom  it  is  primarily  written,  but  also  to  the  experienced  ophthalmologist.  Most 
surely  Dr.  Theobald  has  accomplished  his  purpose." 


EYE,    EAR,    NOSE,    AND    THROAT. 


deSchweinitz    and    Holloway   on   Pulsating    Exoph- 
thalmos 

Pulsating  Exophthalmos.  An  analysis  of  sixty-nine  cases  not  pre- 
viously analyzed.  By  George  E.  deSchweinitz,  M.  D.,  and  Thomas 
B.  Holloway,  M.  D.     Octavo  of  125  pages.     Cloth,  $2.00  net. 

This  monograph  consists  of  an  analysis  of  sixty-nine  cases  of  this  affection 
not  previously  analyzed.  The  therapeutic  measures,  surgical  and  otherwise, 
which  have  been  employed  are  compared,  and  an  endeavor  has  been  made 
to  determine  from  these  analyses  which  procedures  seem  likely  to  prove  of 
the  greatest  value.  It  is  the  most  valuable  contribution  to  ophthalmic  liter- 
ature within  recent  years. 

British  Medical  Journ&I 

"  The  book  deals  very  thoroughly  with  the  whole  subject  and  in  it  the  most  complete  account  of 
the  disease  will  be  found." 

Jackson     on    the     Eye  The  New  (2d)  Edition 

A  Manual  of  the  Diagnosis  and  Treatment  of  Diseases  of  the 
Eye.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor  of  Ophthalmology, 
University  of  Colorado.  i2mo  volume  of  615  pages,  with  184  beautiful 
illustrations.     Cloth,  ^2.50  net. 

The  Medic&l  Record,  New  York 

"  It  is  truly  an  admirable  work.  .  .  .  Written  in  a  clear,  concise  manner,  it  bears  evidence  of  the 
author's  comprehensive  grasp  of  the  subject.  The  term  '  multum  in  parvo'  is  an  appropriate  one  to 
apply  to  this  work." 

Grant  on   Face,   Mouth,   and  Jaws 

A  Text-Book  of  the  Surgical  Principles  and  Surgical  Diseases 
OF  the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  H.  Horace 
Grant,  A.  M.,  M.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Hospital  College  of  Medicine,  Louisville.  Octavo  of  231  pages,  with 
68  illustrations.     Cloth,  ^2.50  net. 

Friedrich   and   Curtis  on   Nose,   Larynx,   and   Ear 

RhINOLOGY,   LARYNGOLOGy,  AND    OtOLOGY,    AND    ThEIR    SIGNIFICANCE 

IN  General  Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited 
by  H.  HoLBROOK  Curtis,  M.  D.,  Consulting  Surgeon  to  the  New  York 
Nose  and  Throat  Hos})ital.  Octavo  volume  of  350  pages.  Cloth, 
$2.50  net. 


GENITO- URINARY  AND    NOSE,     THROAT,     ETC.  9 

Greene  anc)  Brooks* 
Genito-Urinary  Diseases 

Diseases  of    the   Genito=Urinary  Organs  and  the  Kidney.      By 

Robert  H.  Greene,  M.  D.,  Professor  of  Genito-Urinary  Surgery  at 
Fordham  University;  and  Harlow  Brooks,  M.  D.,  Assistant  Pro- 
fessor of  Clinical  Medicine,  University  and  Bellevue  Hospital  Medical 
School.  Octavo  of  605  pages,  illustrated.  Cloth,  ^5.00  net;  Half 
Morocco,  ^6.50  net. 

THE  NEW     (2d)     EDITION 

This  new  work  presents  both  the  medical  and  surgical  sides.  Designed  as  a 
work  of  quick  reference,  it  has  been  written  in  a  clear,  condensed  style,  so  that 
the  information  can  be  readily  grasped  and  retained.  Kidney  diseases  are  very 
elaborately  detailed. 

New  York  Medical  Journal 

"  As  a  whole  the  book  is  one  of  the  most  satisfactory  and  useful  works  on  genito-urinary 
diseases  now  extant,  and  will  undoubtedly  be  popular  among  practitioners  and  students." 

Gleason  on  Nose,  Throat, 
and  Ear 

A   Manual   of   Diseases  of   the    Nose,  Throat,  and    Ear.     By  E. 

Baldwin  Gleason,  M.  D.,  LL.  D.,  Clinical  Professor  of  Otology, 
Medico-Chirurgical  College,  Philadelphia.  i2mo  of  556  pages,  pro- 
fusely illustrated.     Flexible  leather,  $2.50  net. 

FOR    PRACTITIONERS 

Methods  of  treatment  have  been  simplified  as  much  as  possible,  so  that  in 
most  instances  only  those  methods,  drugs,  and  operations  have  been  advised 
which  have  proved  beneficial.  A  valuable  feature  consists  of  the  collection  of 
formulas. 

American  Journal  of  the  Medical  Sciences 

"  For  the  practitioner  who  wishes  a  reliable  guide  in  laryngology  and  otology  there  are  few 
books  which  can  be  more  heartily  commended." 


American  Text=Book  of  Genito=Urinary  Diseases,  Syphilis,  and 
Diseases  of  the  Skin.  Edited  by  L.  Bolton  Bangs,  M.  D.,  and 
W.  A.  Hardaway,  M.  D.  Octavo,  1229  pages,  300  engravings,  20 
colored  plates.     Cloth,  ;^7.oo  net. 


SAUNDKRS'     BOOKS    OX 


StelwagonV 
Diseases  of  the  Skin 


A  Treatise  on  Diseases  of  the  Skin.  By  Henry  W.  Stelwagon, 
M.  D.,  Ph.  D.,  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia.  Octavo  of  1180  pages,  with  280  text-cuts  and 
32  plates.     Cloth,  $6.00  net ;   Half  Morocco,  $7.50  net. 

JUST  READY— THE  NEW  (6th)   EDITION 

The  demand  for  five  editions  of  this  work  in  a  period  of  five  years  indicates 
the  practical  character  of  the  book.  In  this  edition  the  articles  on  Frambesia, 
Oriental  Sore,  and  other  tropical  diseases  have  been  entirely  rewritten.  The  new 
subjects  include  Verruga  Peruana,  Leukemia  Cutis,  Meralgia  Paraesthetica,  Dhobie 
Itch,  and  Uncinarial  Dermatitis. 

George  T.  Elliot,  M.  D.,  Professor  of  De7-matology,  Cornell  University. 

"  It  is  a  book  that  I  recommend  to  my  class  at  Cornell,  because  for  conservative  judgment, 
for  accurate  observation,  and  for  a  thorough  appreciation  of  the  essential  position  of  derma- 
tology, I  think  it  holds  first  place." 


Schamberg^s  Diseases  qf  the  Skin 
and  Eruptive  P evers 


Diseases  of  the  Skin  and  the  Eruptive  Fevers.  By  Jay  F.  Schamberg, 
M.  D.,  Professor  of  Dermatology  and  the  Infectious  Eruptive  Diseases,  Philadel- 
phia Polyclinic.     Octavo  of  534  pages,  illustrated.      Cloth,  $3.00  net. 

THE   CUTANEOUS   MANIFESTATIONS   OF  ALL  DISEASES 

"  The  acute  eruptive  fevers  constitute  a  valuable  contribution,  the  statements  made 
emanating  from  one  who  has  studied  these  diseases  in  a  practical  and  thorough  manner  from 
the  standpoint  of  cutaneous  medicine.  .  .  .  The  views  expressed  on  all  topics  are  con- 
servative, safe  to  follow,  and  practical,  and  are  well  abreast  of  the  knowledge  of  the  present 
time,  both  as  to  general  and  special  pathology,  etiology,  and  treatment." — American  Journal 
of  Medical  Sciences. 


PrSEASFS   OF    THE   SA'/.V. 


Mracek  and  Stelwagon*s 
Diseases  of  the  Skin 

Atlas  and  Epitome  of  Diseases  of  the  Skin.  By  Prof.  Dr.  Franz 
Mracek,  of  Menna.  Edited,  with  additions,  by  Henry  W.  Stelwagon, 
M.  D..  Professor  of  Dermatology  in  the  Jefferson  Medical  College, 
Philadelphia.  With  yy  colored  plates,  50  half-tone  illustrations,  and 
280  pages  of  text.     In  Saunders'  Hand- Atlas  Series.  Clo.,  $4.00  net 

THE    NEW    (2d)    EDITION 

This  volume,  the  outcome  of  years  of  scientific  and  artistic  work,  contains, 
together  with  colored  plates  of  unusual  beaut\-,  numerous  illustrations  in  black, 
and  a  text  comprehending  the  entire  field  of  dermatology.  The  illustrations  are 
all  original  and  prepared  from  actual  cases  in  Mracek"  s  clinic,  and  the  execution 
of  the  plates  is  superior  to  that  of  any,  even  the  most  expensive,  dermatologic 
atlas  hitherto  published. 

Americeoi  Journal  of  the  Medical  Sciences 

"The  advantages  which  we  see  in  this  book  and  which  recommend  it  to  our  minds  are: 
First,  its  handiness ;  secondly,  the  plates,  which  are  excellent  as  regards  drawing,  color,  and  the 
diagnostic  points  which  they  bring  out." 

Mracek  and  Bangfs* 
Syphilis  and  Venereal 

Atlas    and    Epitome   of    Syphilis    and    the    Venereal    Diseases. 

By  Prof.  Dr.  Fraxz  Mracek,  of  Vienna.  Edited,  with  additions,  by 
L.  Bolton  Bangs,  M.  D.,  late  Prof,  of  Genito-Urinar}-  Surger)-.  Univer- 
sity and  Bellevue  Hospital  Medical  College,  New  York.  With  71 
colored  plates  and  122  pages  of  text.  Cloth,  S3. 50  net.  In  Saunders' 
Hand- At  I  as  Scries. 

CONTAINING   71   COLORED   PLATES 

According  to  the  unanimous  opinion  of  numerous  authorities,  to  -whom  the 
original  illustrations  of  this  book  were  presented,  they  surpass  in  beauty  anything 
of  the  kind  that  has  been  produced  in  this  field,  not  only  in  Germany,  but 
throughout  the  literature  of  the  world. 

Robert  L.  Dickinson,  M.  D., 

Art  Editor  of  "  The  American  Text-Book  of  Obstetrics." 
"  The  book  that  appeals  instantly  to  me  for  the  strikingly  successful,  valuable,  and  graphic 
character  of  its  illustrations  is  the  'Atlas  of  Sj'philis  and  the  Venereal  Diseases.'     I  know  of 
■nothing  in  this  country  that  can  compare  with  it." 


12  SAUNDERS'  BOOKS   ON 

Holland's  Medical 
Chemistry  and  Toxicology 

A  Text=Book  of  Medical  Chemistry  and  Toxicology.  By  James 
W.  Holland,  M.D.,  Professor  of  Medical  Chemistry  and  Toxicology, 
and  Dean,  Jefferson  Medical  College,  Philadelphia.  Octavo  of  655 
pages,  fully  illustrated.     Cloth,  $3.00  net. 

THE  NEW  (2d)   EDITION 

Dr,  Holland's  work  is  an  entirely  new  one,  and  is  based  on  his  forty  years' 
practical  experience  in  teaching  chemistry  and  medicine.  It  has  been  subjected  to 
a  thorough  revision,  and  enlarged  to  the  extent  of  some  sixty  pages.  The  additions 
to  be  specially  noted  are  those  relating  to  the  electronic  theory,  chemical  equilib- 
rium, Kjeldahl's  method  for  determining  nitrogen,  chemistry  of  foods  and  their 
changes  in  the  body,  synthesis  of  proteins,  and  the  latest  improvements  in  urinary 
tests.      More  space  is  given  to  toxicology  than  in  any  other  text-book  on  chemistry. 

American  Medicine 

"  Its  statements  are  clear  and  terse  ;  its  illustrations  well  chosen;  its  development  logical,, 
systematic,  and  comparatively  easy  to  follow.  .  .  .  We  heartily  commend  the  work." 

Grtinwald  and  Newcomb*s 
Mouth,  Pharynx,  and  Nose 

Atlas  and  Epitome  of  Diseases  of  the  Moutli,  Pliarynx,  and 
Nose.  By  Dr.  L.  Grunwald,  of  Munich,  From  the  Second  Revised 
and  Enlarged  German  Edition.  Edited,  with  additions,  by  James  E. 
Newcomb,  M.  D.,  Instructor  in  Laryngology,  Cornell  University  Medical 
School.  With  102  illustrations  on  42  colored  lithographic  plates,  41 
text-cuts,  and  219  pages  of  text.  Cloth,  ^3.00  net.  In  Sannders" 
Hand- Atlas  Series. 

INCLUDING   ANATOMY   AND   PHYSIOLOGY 

In  designing  this  atlas  the  needs  of  both  student  and  practitioner  were  kept 
constantly  in  mind,  and  as  far  as  possible  typical  cases  of  the  various  diseases 
were  selected.  The  illustrations  are  described  in  the  text  in  exactly  the  same  way 
as  a  practised  examiner  would  demonstrate  the  objective  findings  to  his  class. 
The  illustrations  themselves  are  numerous  and  exceedingly  well  executed.  The 
editor  has  incorporated  his  own  valuable  experience,  and  has  also  included  exten- 
sive notes  on  the  use  of  the  active  principle  of  the  suprarenal  bodies. 

American  Medicine 

"  Its  conciseness  without  sacrifice  of  clearness  and  thoroughness,  as  well  as  the  excellence 
of  text  and  illustrations,  are  commendable." 


URINE  AND   IMPOTENCE.  13 

O^den  on  the  Urine 


Clinical  Examination  of  Urine  and  Urinary  Diagnosis.     A  Clinical 

Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Medical  Chemist  to  the  Metro- 
politan Life  Insurance  Company,  New  York.  Octavo,  418  pages,  54 
text  illustrations,  and  a  number  of  colored  plates.     Cloth,  ;^3.0O  net. 

THE  NEW  (3d)  EDITION 

In  this  edition  the  work  has  been  brought  absolutely  down  to  the  present  day. 
Urinary  examinations  for  purposes  of  life  insurance  have  been  incorporated,  because 
a  large  number  of  practitioners  are  often  called  upon  to  make  such  analyses. 
Special  attention  has  been  paid  to  diagnosis  by  the  character  of  the  urine,  the 
diagnosis  of  diseases  of  the  kidneys  and  urinary  passages  ;  an  enumeration  of  the 
prominent  clinical  symptoms  of  each  disease  ;  and  the  peculiarities  of  the  urine 
in  certain  general  diseases. 

The  Lancet,  London 

"  We  consider  this  manual  to  have  been  well  compiled  ;  and  the  author's  own  experience, 
so  clearly  stated,  renders  the  volume  a  useful  one  both  for  study  and  reference." 

Vecki*s  Sexual  Impotence 


The  Pathology  and  Treatment  of  Sexual  Impotence.  By  Victor 
G.  Vecki,  M.  D.  From  the  Second  Revised  and  Enlarged  German 
Edition.      i2mo  volume  of  329  pages.     Cloth,  ^2.00  net. 

THIRD  EDITION,  REVISED  AND  ENLARGED 

The  subject  of  impotence  has  but  seldom  been  treated  in  this  country  in  the 
truly  scientific  spirit  that  its  pre-eminent  importance  deserves,  and  this  volume  will 
come  to  many  as  a  revelation  of  the  possibilities  of  therapeutics  in  this  important 
field.  The  reading  part  of  the  English-speaking  medical  profession  has  passed 
judgment  on  this  monograph.  The  whole  subject  of  sexual  impotence  and  its 
treatment  is  discussed  by  the  author  in  an  exhaustive  and  thoroughly  scientific 
manner.  In  this  edition  the  book  has  been  thoroughly  revised,  and  new  matter 
has  been  added,  especially  to  the  portion  dealing  with  treatment. 

Johns  Hopkins  Hospital  Bulletin 

"  A  scientific  treatise  upon  an  important  and  much  neglected  subject.  .  .  .  The  treatment 
of  impotence  in  general  and  of  sexual  neurasthenia  is  discriminating  and  judicious." 


14  SAUNDERS'    BOOKS   ON 

Wells*   Chemical  Pathology 

Chemical  Pathology.  Being  a  discussion  of  General  Path- 
ology from  the  Standpoint  of  the  Chemical  Processes  Involved. 
By  H.  Gideon  Wells,  Ph.  D.,  M.  D.,  Assistant  Professor  of 
Pathology  in  the  University  of  Chicago.  Octavo  of  549  pages. 
Cloth,  ^3.25  net;   Half  Morocco,  $4.7^  "^t. 

Dr.  Wells  here  concisely  presents  the  latest  work  systematically  con- 
sidering the  subject  of  general  pathology  from  the  standpoint  of  the  chemical 
processes  involved.  Special  chapters  are  devoted  to  Diabetes  and  to  Uric- 
acid  Metabolism  and  Gout. 

Wm.  H.  Welch,   M.  D.,  Professor  of  Pathology,  Johns  Hopkins  University. 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and 
I  shall  be  glad  to  recommend  it  to  my  students." 


The  New   (2d)  Edition 


Saxe*s  Urinalysis 

Examination  of  the  Urine.  By  G.  A.  De  Santos  Saxe,  M.  D., 
Instructor  in  Genito-Urinary  Surgery,  York  Post-graduate  Medical 
School  and  Hospital.  i2mo  of  448  pages,  fully  illustrated. 
Cloth,  $175  net. 

This  work  is  intended  as  an  aid  in  diagnosis,  by  interpreting  the  clinical 
significance  of  the  chemic  and  microscopic  urinary  findings. 

Francis  Cairter  Wood,  M.  D.,    Adjunct  Professor  of  Clinical  Pathology,   Columbia    Uni- 
versity. 

"It  seems  to  me  to  be  one  of  the  best  of  the  smaller  works  on  this  subject ;  it  is,, 
indeed,  better  than  a  good  many  of  the  larger  ones." 

deSchweinitz  and  Randall   on  the  Eye,  Ear» 
Nose,  and  Throat 

American  Text-Book  of  Diseases  of  the  Eye,  Ear,  Nose,  and 
Throat.  Edited  by  G.  E.  de  Schweinitz,  M.  D.,  Professor  of 
Ophthalmology  in  the  University  of  Pennsylvania ;  and  B.  Alex- 
ander Randall,  M.  D.,  Clinical  Professor  of  Diseases  of  the  Ear 
in  the  University  of  Pennsylvania.  Imperial  octavo,  125 1  pages^ 
with  766  illustrations,  59  of  them  in  colors.  Cloth,  ^7.00  net ; 
Half  Morocco,  ^8.50  net. 

Grunwald  and  Grayson  on  the  Larynx 

Atlas  and   Epitome  of  Diseases  of  the  Larynx.     By  Dr.  L. 

Grunwald,  of  Munich.  Edited,  with  additions,  by  Charles  P. 
Grayson,  M.  D.,  Clinical  Professor  of  Laryngology  and  Rhinology, 
University  of  Pennsylvania.  With  107  colored  figures  on  44 
plates,  25  text-cuts,  and  103  pages  of  text.  Cloth,  ^2.50  net. 
hi  Saunders'  Hand-Atlas  Series. 


CHEMISTRY,   SKIN,  AND   VENEREAL   DISEASES.  l^ 

American  Pocket  Dictionary  sixth  Edition 

The  American  Pocket  Medical  Dictionary.    Edited  by  W.  A. 

Newman  Dorland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital 

of  the  University  of  Pennsylvania.     Containing-  the  pronunciation 

and  definition  of  the  principal  words  used  in  medicine  and  kindred 

sciences.      598  pages.     Flexible   leather,  v/ith   gold  edges,   ^i.oo 

net;  with  thumb  index,  $1.25  net. 

James  W.  Holland.  M.  D.. 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  Jefferson  Medical  College. 
Philadelphia, 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  ] 
can  recommend  it  to  our  students  without  reserve." 

Stelwa^on's  Essentials  of  Skin  7th  Edition 

Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stel- 
wagon,  M.  D.,  Ph.D.,  Professor  of  Dermatology  in  the  Jeffer- 
son Medical  College,  Philadelphia.  Post-octavo  of  291  pages, 
with  72  text-illustrations  and  8  plates.  Cloth,  ^i.oo  net.  In 
Saunders'  Question-  Coinpend  Series. 
The  Medical  News 

"  In  line  with  our  present  knowledge  of  diseases  of  the  skin.  .  .  .  Continues  to  main- 
tain the  high  standard  of  excellence  for  which  these  question  compends  have  been  noted." 

Wolffs  Medical  Chemistry  New  (7th)  Edition 

Essentials  of  Medical  Chemistry,  Organic  and  Inorganic. 
Containing  also  Questions  on  Medical  Physics,  Chemical  Physiol- 
ogy, Analytical  Processes,  Urinalysis,  and  Toxicology.  By  Law- 
rence Wolff,  M.  D.,  Late  Demonstrator  of  Chemistry,  Jefferson 
Medical  College.  Revised  by  A.  Ferree  Witmer,  Ph.  G.,  M.  D., 
Formerly  Assistant  Demonstrator  of  Physiology,  University  of 
Pennsylvania.  Post-octavo  of  222  pages.  Cloth,  ^i.oo  net.  In 
Saunders^  Question- Compend  Series. 

Martin's  Minor  Surgery,  Bandaging',  and  the  Venereal 

Diseases  second  Edition,  Revised 

Essentials  of  Minor  Surgery,  Bandaging,  and  Venereal 
Diseases.  By  Edward  Martin,  A.  M.,  M.  D.,  Professor  of  Clin- 
ical Surgery,  University  of  Pennsylvania,  etc.  Post-octavo,  166 
pages,  with  78  illustrations.  Cloth,  ^^i.oo  net.  In  Saunders* 
Question-  Compend  Series. 


1 6  URINE,  EYE,  EAR,  NOSE,  AND    THROAT. 

Wolfs  Examination  of  Urine 

A  Labukatokv  Handbook  of  Physiologic  Chemistry  and 
Urine-examination.  By  Charles  G.  L.  Wolf,  M.D.,  Instructor  in 
Physiologic  Chemistry,  Cornell  University  Medical  College,  New 
York.  i2mo  volume  of  204  pages,  fully  illustrated.  Cloth,  $1.25  net, 
British  Medical  Journal 

"  The  methods  of  examining  the  urine  are  very  fully  described,  and  there  are  at  the 
end  of  the  book  some   extensive   tables  drawn  up  to  assist  in  urinary  diagnosis." 

Jackson's  Essentials  of  Eye  Third  Revised  Edition 

Essentials  of  Refraction  and  of  Diseases  of  the  Eve,  By 
Edward  Jackson,  A.  M.,  M,  D.,  Emeritus  Professor  of  Diseases  of 
the  Eye,  Philadelphia  Polyclinic.  Post-octavo  of  261  pages,  82  illus- 
trations. Cloth,  $1.00  net.  In  Smindcrs'  Qncstion-Conipend  Series. 
Johns  Hopkins  Hospital  Bulletin 

"  The  entire  ground  is  covered,  and  the  points  that  most  need  careful  elucidation 
are  made  clear  and  easy." 

Gleason's  Nose  and  Throat  Fourth  Edition,  Revised 

Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  B. 
Gleason,  S.  B.,  M.  D.,  Clinical  Professor  of  Otology,  Medico- 
Chirurgical  College,  Philadelphia,  etc.  Post-octavo,  241  pages,  1 12 
illustrations.  Cloth,  $1.00  net.  I)i  Saunders'  Question  Compends, 
The  Lancet,  London 

"  The  careful  description  which  is  given  of  the  various  procedures  would  be  sufficient 
to  enable  most  people  of  average  intelligence  and  of  slight  anatomical  knowledge  to 
make  a  very  good  attempt  at  laryngoscopy." 

Gleason*s  Diseases  of   the  Ear  Third  Edition,  Revbed 

Essentials  of  Dise.ases  of  the  Ear.     By  E.  B.  Gleason,  S.  B., 
M.  D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical  College, 
Phila.,  etc.     Post-octavo   volume  of  214  pages,  with   114  illustra- 
tions.    Cloth,  $1.00  net.      Li  Saunders  Question- Compend  Sei'ies. 
Bristol  Medico-Chirurgical  Journal 

"  We  know  of  no  other  small  work  on  ear  diseases  to  compare  with  this,  either  in 
freshness  of  style  or  completeness  of  information." 

lA/ilcox  on  Genito-Urinary  and  Venereal  Diseases 

The   New   (2d)   Edition 

Essentials  of  Genito-Urinary  and  Venereal  Diseases,  By 
Starling  S,  Wilcox,  M.  D.,  Lecturer  on  Genito-Urinar}^  Diseases 
and  Syphilology,  Starling-Ohio  Medical  College,  Columbus.  1 2mo 
of  321  pages,  illustrated.     Cloth,  ;^i. 00  net.     Saunders'  Compends. 

Stevenson's  Photoscopy 

Photoscopy  (Skiascopy  or  Retinoscopy).  By  Mark  D.  Stev- 
enson, M.  D.,  Ophthalmic  Surgeon  to  the  Akron  City  Hospital. 
i2mo  of  126  pages,  illustrated.  Cloth,  $1.25  net. 

Edward  Jackson,   M.  D.,  University  of  Colorado. 

"  It  is  well  written  and  will  prove  a  valuable  help.  Your  treatment  of  the  emergent 
pencil  of  rays,  and  the  part  falling  on  the  examiner's  eye,  is  decidedly  better  than  any 
previous  account." 


